Archive for category Virtual Reality

[ARTICLE] Leap Motion-based virtual reality training for improving motor functional recovery of upper limbs and neural reorganization in subacute stroke patients – Full Text



Virtual reality is nowadays used to facilitate motor recovery in stroke patients. Most virtual reality studies have involved chronic stroke patients; however, brain plasticity remains good in acute and subacute patients. Most virtual reality systems are only applicable to the proximal upper limbs (arms) because of the limitations of their capture systems. Nevertheless, the functional recovery of an affected hand is most difficult in the case of hemiparesis rehabilitation after a stroke. The recently developed Leap Motion controller can track the fine movements of both hands and fingers. Therefore, the present study explored the effects of a Leap Motion-based virtual reality system on subacute stroke. Twenty-six subacute stroke patients were assigned to an experimental group that received virtual reality training along with conventional occupational rehabilitation, and a control group that only received conventional rehabilitation. The Wolf motor function test (WMFT) was used to assess the motor function of the affected upper limb; functional magnetic resonance imaging was used to measure the cortical activation. After four weeks of treatment, the motor functions of the affected upper limbs were significantly improved in all the patients, with the improvement in the experimental group being significantly better than in the control group. The action performance time in the WMFT significantly decreased in the experimental group. Furthermore, the activation intensity and the laterality index of the contralateral primary sensorimotor cortex increased in both the experimental and control groups. These results confirmed that Leap Motion-based virtual reality training was a promising and feasible supplementary rehabilitation intervention, could facilitate the recovery of motor functions in subacute stroke patients. The study has been registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-OCH-12002238).


Chronic conditions such as stroke are becoming more prevalent as the world’s population ages (Christensen et al., 2009). Although the number of fatalities caused by stroke has fallen in most countries, stroke is still a leading cause of acquired adult hemiparesis (Langhorne et al., 2009; Liu and Duan, 2017). Up to 85% of patients who survive a stroke experience hemiparesis, resulting in impaired movement of an arm and hand (Nakayama et al., 1994). Among them, a large proportion (46% to 95%) remain symptomatic six months after experiencing an ischemic stroke (Kong et al., 2011). The loss of upper limb function adversely affects the quality of life and impedes the normal use of other body parts. The motor function recovery of the upper limbs is more difficult than that of the lower extremities (Kwakkel et al., 1996; Nichols-Larsen et al., 2005; Día and Gutiérrez, 2013). Functional motor recovery in the affected upper extremities in patients with hemiparesis is the primary goal of physical therapists (Page et al., 2001). Evidence suggests that repetitive, task-oriented training of the paretic upper extremity is beneficial (Barreca et al., 2003; Wolf et al., 2006). Rehabilitation intervention is a critical part of the recovery and studies have reported that intensive repeated practice is likely necessary to modify the neural organization and favor the recovery of the functional upper limb motor skills of stroke survivors (Brunnstrom, 1966; Kopp et al., 1999; Taub et al., 1999; Wolf et al., 2006; Nudo, 2011). Meta-analyses of clinical trials have indicated that longer sessions of practice promote better outcomes in the case of impairments, thus improving the daily activities of people after a stroke (Nudo, 2011; Veerbeek et al., 2014; Sehatzadeh, 2015; French et al., 2016). However, the execution of these conventional rehabilitation techniques is tedious, resource-intensive, and often requires the transportation of patients to specialized facilities (Jutai and Teasell, 2003; Teasell et al., 2009).

Virtual reality training is becoming a promising technology that can promote motor recovery by providing high-intensity, repetitive, and task-orientated training with computer programs simulating three-dimensional situations in which patients play by moving their body parts (Saposnik et al., 2010, 2011; Kim et al., 2011; Laver et al., 2015; Tsoupikova et al., 2015). The gaming industry has developed a variety of virtual reality systems for both home and clinical applications (Saposnik et al., 2010; Bao et al., 2013; Orihuela-Espina et al., 2013; Gatica-Rojas and Méndez-Rebolledo, 2014). The most difficult task related to hemiparesis rehabilitation after a stroke is the functional recovery of the affected hand (Carey et al., 2002). To facilitate the functional recovery of a paretic hand along with that of the proximal upper extremity, an ideal virtual reality system should be able to track hand position and motion, which is not a feature of most existing virtual reality systems (Jang et al., 2005; Merians et al., 2009). The leap motion controller developed by Leap Motion ( provides a means of capturing and tracking the fine movements of the hand and fingers, while controlling a virtual environment requiring hand-arm coordination as part of the practicing of virtual tasks (Iosa et al., 2015; Smeragliuolo et al., 2016).

Most virtual reality studies have often only involved patients who have experienced chronic stroke (Piron et al., 2003; Yavuzer et al., 2008; Saposnik et al., 2010; da Silva Cameirao et al., 2011). For patients in the chronic stage, who had missed the window of opportunity present at the acute and subacute stages (in which the brain plasticity peaks), rehabilitation-therapy-induced neuroplasticity can only be effective within a relatively narrow range (Chen et al., 2002). No motor function recovery of the hands, six months after the onset of a stroke, indicates a poor prognosis for hand function (Duncan et al., 1992).

We hypothesized that Leap Motion-based virtual reality training would facilitate motor functional recovery of the affected upper limb, as well as neural reorganization in subacute stroke patients. Functional magnetic resonance imaging (fMRI), also called blood oxygenation level-dependent fMRI (BOLD-fMRI), is widely used as a non-invasive, convenient, and economical method to examine cerebral function (Ogawa et al., 1990; Iosa et al., 2015; Yu et al., 2016). In the present study, we evaluated the brain function reorganization by fMRI, as well as the motor function recovery of the affected upper limb in patients with subacute stroke using Leap Motion-based virtual reality training.[…]

Continue —>  Leap Motion-based virtual reality training for improving motor functional recovery of upper limbs and neural reorganization in subacute stroke patients Wang Zr, Wang P, Xing L, Mei Lp, Zhao J, Zhang T – Neural Regen Res

Figure 1: Leap Motion-based virtual reality system and training games.
(A, B) Leap Motion-based virtual reality system; (C) petal-picking game; (D) piano-playing game; (E) robot-assembling game; (F) object-catching with balance board game; (G) firefly game; (H) bee-batting game.




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[ARTICLE] Active rehabilitation training system for upper limb based on virtual reality – Full Text


In this article, an active rehabilitation training system based on the virtual reality technology is designed for patients with the upper-limb hemiparesis. The six-axis inertial measurement unit sensors are used to acquire the range of motion of both shoulder and elbow joints. In order to enhance the effect of rehabilitation training, several virtual rehabilitation training games based on the Unity3D engine are designed to complete different tasks from simple level to complicated level. The purpose is to increase the patients’ interest during the rehabilitation training. The basic functions of the virtual rehabilitation task scenes are tested and verified through the single-joint training and the multi-joint compounding training experiments. The experimental results show that the ranges of motion of both shoulder and elbow joints can reach the required ranges of a normal human in the rehabilitation training games. Therefore, the system which is easy to wear, low cost, wireless communication, real-time data acquisition, and interesting virtual rehabilitation task games can provide an effective rehabilitation training process for the upper-limb hemiparesis at home.

The upper limb has many degrees of freedom, and it is also a complex part of the human body by which people can accomplish fine movements during their activities in daily life. With the intensification of the aging problem in the world, the amount of stroke hemiparesis has shown a growing trend, especially in China, which has an enormous population.1 Approximately 30%–50% of these stroke survivors will suffer from chronic hemiparesis, especially involving their hands. In addition, spinal cord injury (SCI) and traffic accident survivors may also find limb movements’ disorder. Injury within the cervical region of the cord leads to tetraplegia, which leads to impairment of all four limbs. An estimated result shows that 55% of new cases will result in tetraplegia, while the other 45% will experience paraplegia due to injury below the cervical level.2Limb hemiparesis which is caused by stroke, SCI, or traffic accidents not only gives the patient’s daily life a great deal of inconvenience and even more makes the patient suffer from great mental pain but also brings a heavy stress and medical burden for the patient’s family and society. Technology has been developed in an effort to facilitate rehabilitation for the patient. Upper-limb rehabilitation is one of the fastest growing areas in modern neurorehabilitation. Quality of life can be improved with efficient therapy.3 At present, rehabilitation therapy of upper limb with traditional rehabilitation therapy is commonly used, that is, rehabilitation therapists perform rehabilitation trainings on individuals. Now with the development of robot technology, the rehabilitation of robot-assisted training is also rising up. The MIT-Manus4 is an example of end-effector-based and arm-rehabilitation robotic device, while the ARMin device5 is an example of arm-rehabilitation exoskeletons which also allows pronation/supination of the lower arm and wrist flexion/extension. It could be operated in three modes: passive mobilization, active game-supported arm therapy, and active training of activities of daily living (ADLs). The end-effector-based robots have practical advantages (usability, simplicity, and cost-effectiveness), and exoskeleton robots have biomechanical advantages (better guidance). Currently, the automatic rehabilitation devices on market as mentioned above are mostly complex and expensive, which are often used in the hospitals and clinics are not affordable to ordinary patients. Therefore, one of the research objectives aims to develop the upper-limb rehabilitation training system with minimal structure and low cost and can be used in patient’s home. But in China, it can be seen that patients with upper-limb orthosis in home is only for fixing the arm and just move autonomously according to the setting angle. The researches on intelligent domestic rehabilitation device just begins, most of which are in the experimental stage and not yet market oriented.6,7

Another problem is that the patients are treated with low initiative and dull training process which does not motivate them, while the treatment effect is not obvious.8,9 Computer games based on virtual reality (VR) are a good way to mobilize the patients’ initiative in the training, so the rehabilitation effect on a particular movement task will be greatly improved.10 VR environments provide an excellent method to manipulate task conditions in training. The effects and the intensity of training can be enhanced and designed more challenging, since the implementation of VR can build a channel both visual and haptic communication can be involved in. The research on VR system which is applied to rehabilitation training was initiated a few years ago. Mazzone et al.11 made a study on the effect of rehabilitation training for patients with shoulder joints training using VR technology. This study aimed to determine whether performance of shoulder exercises in virtual reality gaming (VRG) results in similar muscle activation as non-VRG exercise. The conclusion was drawn that exercise with VRG should be effective to reduce shoulder pain caused by spinal injury. Fischer et al.12 conducted a preliminary study claim that stroke patients could assist themselves in training their hands in the virtual environment. The purpose of this pilot study was to investigate the impact of assisted motor training in a virtual environment on hand function for the stroke survivors. Participants had 6 weeks of training in reach-to-grasp of both virtual and actual objects. After the training period, participants in all three groups demonstrated a decrease in time to perform some of the functional tasks. These designs based on VR have achieved some success and then the second research objective is to add the VR technology to the intelligent domestic rehabilitation device. These studies are mainly designed for the single joint of the upper-limb rehabilitation training. Therefore, it is necessary to carry out the research on multi-joint combined training device for patients who can just stay home by training with VR tasks of adjustable game levels.

Another important element which needs to be considered as an ultimate success using at home is its ease of use. Therefore, simple active rehabilitation device should be developed. The setup time of such device should be fast, besides measurement, treatment approaches, and incorporating gaming, and should provide intuitive interfaces that can be directly utilized by the individuals. This study will introduce an active rehabilitation training system for upper limb based on VR technology, which has some advantages such as simple structure, easy to manipulate, and portable for household. It also mobilizes patients’ initiative with adjustable difficulty level of VR tasks so that the individuals’ rehabilitation effect of the upper limb is obviously improved.

The active rehabilitation training system for upper limb based on VR is designed for the pronation/supination and flexion movement trainings of the elbow joint and the extension/flexion and abduction exercises of the shoulder joint. By adding the games in training processes, the patients may actively participate in rehabilitation trainings, while the efficiency will be greatly improved. The portable and easy-to-use design of this system can effectively reduce the problem of the medical resources shortage in the rehabilitation field.

Overall scheme of the system

The system is composed of two parts: the upper-limb posture detection system and the virtual rehabilitation training task scene, as shown in Figure 1.


Figure 1. Schematic diagram of an active rehabilitation training system for upper limb based on VR.


Continue —> Active rehabilitation training system for upper limb based on virtual realityAdvances in Mechanical Engineering – Jianhai Han, Shujun Lian, Bingjing Guo, Xiangpan Li, Aimin You, 2017

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[WEB SITE] Hospital wins patent in VR treatment for cognitive disorders.

A local hospital is drawing attention by winning a patent in cognitive rehabilitation treatment using a 3D virtual reality (VR) technology.

The Gil Medical Center and Gachon University’s industry-university cooperation foundation said on Monday they registered the patent in “a method and system using 3D virtual reality for the treatment of cognitive impairment.” Professor Lee Ju-kang of Gachon University Gil Medical Center’s physical medicine and rehabilitation department had developed the system.

The invention allows doctors to treat a wide range of cognitive disorders, including dementia, with all the different kinds of virtual space. Physicians expect better treatment results with the new technology, which offers virtual areas such as homes that are more familiar to patients than hospital’s treatment rooms.

To build 3D background information, the user of the program should visit the patient’s home and scan it first. Then, the user can save it as a database.

“Existing dementia treatments are quite limited, as most of them focus on prevention of further progress rather than on cure. Thus, it is becoming more important to use rehabilitation treatment to prevent dementia-derived adjustment disorders or accidents in daily life,” the medical center stated in the patent explanation.

“Existing treatments include cognitive rehabilitation offered in a limited environment such as hospital’s treatment room and cognitive training through a few computer programs, which are far from real life,” it went on to say. “By generating 3D virtual reality, we have developed a system to give patients easier access to necessary environment and targets and treat their cognitive impairment.”

Earlier, the hospital unveiled a plan to open a “VR Life Center” next January to treat patients with post-traumatic stress disorder and panic disorder.

“If we combine VR technology with medical treatment software, we can reenact an environment, which is difficult to visit in reality and expect better treatment results,” the hospital said. “VR treatments have already been used as a psychological treatment for a phobia and an addiction and have proven effective.”

via Hospital wins patent in VR treatment for cognitive disorders – Korea Biomedical Review

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[WEB SITE] Post-Stroke Rehab Benefits From Virtual Reality

Patients from 5 rehabilitation centers were enrolled within 12 weeks after a stroke.

Patients from 5 rehabilitation centers were enrolled within 12 weeks after a stroke.

HealthDay News — Virtual reality (VR) training is as effective as conventional training for upper extremity rehabilitation after stroke, according to a study published in Neurology.

Iris Brunner, PhD, from the University of Bergen in Norway, and colleagues randomized 120 patients with upper extremity motor impairment within 12 weeks after stroke to receive VR or CT as an adjunct to standard rehabilitation. Participants underwent at least 16 60-minute training sessions over a four-week period.

The researchers found that there were no between-group differences for any of the outcome measures.

Improvement of upper extremity motor function assessed with the Action Research Arm Test was similar between the groups at the post-intervention (P=.714) and follow-up (P=.777) assessments. Improvements were seen in patients from both groups from baseline to the post-intervention assessment and from baseline to follow-up. Improvements were similar in subgroup analysis of mild to moderate versus severe upper extremity paresis.

“Additional upper extremity VR training was not superior but equally as effective as additional CT in the subacute phase after stroke. VR may constitute a motivating training alternative as a supplement to standard rehabilitation,” conclude the authors.


Brunner I, Skouen JS, Hofstad H, et al. Virtual reality training for upper extremity in subacute stroke (VIRTUES): A multicenter RCT [published online November 15, 2017]. Neurology. doi:10.1212/WNL.0000000000004744.

via Post-Stroke Rehab Benefits From Virtual Reality

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[WEB SITE] VR could trick stroke victims’ brains toward recovery.

Could virtual reality help stroke survivors regain motor function?

That’s a question Sook-Lei Liew is looking to answer.

Liew, an assistant professor at the University of Southern California and an affiliate of the Stevens Neuroimaging and Informatics Institute at the Keck School of Medicine, was inspired by research from Mel Slater and Jeremy Bailenson on embodiment in VR. If someone’s given a child’s body in VR, for example, they might start exhibiting more childlike behavior.

She wondered if giving stroke survivors with motor impairments a virtual avatar that moves properly could help promote brain plasticity (or the ability to change) and recovery. Maybe it would eventually lead to them to moving an impaired limb again.


USC researcher Sook-Lei Liew and her partners are testing to see whether virtual reality could help with stroke rehab. Nate Jense

“So, kind of like tricking the brain through visual input,” said Liew, who is also director of the Neural Plasticity and Neurorehabilitation Laboratory. “There’s a lot of emerging evidence from neuroscience and psychology that was showing that you can really identify [with the avatar], and it changes your behavior based on the avatar you’re given in VR.”

Virtual reality is a computer-generated simulation of a 3D environment. Using a VR headset with lenses that feed images to the eyes, a person can be virtually transported to another location, or interact with a setting in a seemingly realistic way. It’s commonly been used in gaming, but it’s being tested in other environments, too — like rehab.

Implementing VR in health care and patient treatment isn’t new. It’s been used to help people overcome phobias and anxiety disorders. But the application is starting to take off now that the technology is more developed and commercially available. Some medical schools are looking to train students with virtual simulations, and it’s even helping midwives learn how to deliver babies.

Liew’s research team has been working on a study for about two years called REINVENT, an acronym for Rehabilitation Environment using the Integration of Neuromuscular-based Virtual Enhancements for Neural Training. The researchers also collaborated with the USC Institute for Creative Technologies to develop the prototype.

The process works by using a brain-computer interface, which takes a signal from the brain and uses it to control another device: a computer, a robot or, in REINVENT’s case, an avatar in VR.

Next, researchers read electrical signatures of brain activity from the surface of the scalp using electroencephalography, or EEG, for short. The team also uses electromyography, which studies the electrical activity of the muscles. That can tell them whether somebody’s moving or if they’re trying to move.

Those signals are then fed into a program on a laptop. The program has thresholds so that when specific signals in the brain or muscle activity that correspond to an attempt to move are detected, they drive the movement of a virtual arm. The resulting visual feedback through a VR headset could help strengthen neural pathways from the damaged motor cortex to the impaired arm or limb.

While the researchers could theoretically extend this process to a patient’s lower limbs, Liew said it can be dangerous for someone with a motor impairment in the lower extremities to try to move with VR, so seated studies are much safer.

The research group recently finished testing the prototype using an Oculus DK2 with 22 healthy older adults, who provided a sample of what the brain and muscle signals look like when they move. They’re now starting to test with stroke patients in a controlled lab setting, aiming to work with 10 in the short term and hundreds in the long term, in both clinical and home environments.

The team also found that giving people neurofeedback of the virtual arm moving in a VR headset was more effective than simply showing it on a screen.

“Their brain activity in the motor regions that we’re trying to target is higher, and they’re able to control the brain-computer interface a little bit better and faster,” Liew said. “It makes the case that there is an added benefit from doing this in virtual reality, which is one of the first things we wanted to know.”

An unclear future

Because VR is still a relatively new technology, there are many unanswered questions on the best ways to use it in the medical profession.

“For the most part, nobody knows how to make great VR experiences, for business or consumer,” Gartner analyst Brian Blau said. “Over time, those issues will get resolved. But for the medical industry, they have the extra added bonus of having even more types of physical behaviors that they have to either mimic or want to measure.”

And while the possibilities for VR in health care are exciting, Liew is careful not to get ahead of herself.

“We think that VR is a promising medium, but we’re moving ahead cautiously,” she said. “A lot of the work that we’re trying to do is to test assumptions, because there’s a lot of excitement about VR, but there’s not that much that’s scientifically known.”

Only time — and plenty of research — will tell.

Tech Enabled: CNET chronicles tech’s role in providing new kinds of accessibility.

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[WEB SITE] Virtual Reality As Effective As Standard Training for Post-Stroke Rehabilitation.

Improvements were similar in subgroup analysis of mild to moderate vs severe upper extremity paresis.

Improvements were similar in subgroup analysis of mild to moderate vs severe upper extremity paresis

HealthDay News — Virtual reality (VR) training is as effective as conventional training for upper extremity rehabilitation after stroke, according to a study published online in Neurology.

Iris Brunner, PhD, from the University of Bergen in Norway, and colleagues randomized 120 patients with upper extremity motor impairment within 12 weeks after stroke to receive VR or CT as an adjunct to standard rehabilitation. Participants underwent at least 16 60-minute training sessions over a 4-week period.

The researchers found that there were no between-group differences for any of the outcome measures. Improvement of upper extremity motor function assessed with the Action Research Arm Test was similar between the groups at the post-intervention (=.714) and follow-up (=.777) assessments.

Improvements were seen in patients from both groups from baseline to the post-intervention assessment and from baseline to follow-up. Improvements were similar in subgroup analysis of mild to moderate vs severe upper extremity paresis.

“Additional upper extremity VR training was not superior but equally as effective as additional CT in the subacute phase after stroke. VR may constitute a motivating training alternative as a supplement to standard rehabilitation,” concluded the authors.


Brunner I, Skouen JS, Hofstad H, et al. Virtual reality training for upper extremity in subacute stroke (VIRTUES): a multicenter RCT [published online November 15, 2017]. Neurology. doi:10.1212/WNL.0000000000004744

via Virtual Reality As Effective As Standard Training for Post-Stroke Rehabilitation

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[WEB SITE] Games, Gloves, and Grip: PTs Rehab Arms and Hands Post-Stroke With YouGrabber

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Playing virtual reality games could be as effective as adding extra physical therapy sessions to a stroke patient’s rehab regimen, according to researchers.

“It is not a question of choosing one thing over the other, rather of having different training alternatives to provide variation,” says Iris Brunner, author of a study, published recently in Neurology, that explored a variety of medical uses for virtual reality.

“Virtual reality cannot replace physical therapy. But it can be experienced as a game, motivating patients to do an extra treatment session,” adds Brunner, associate professor with the University of Aarhus and Hammel Neurocenter, in Denmark.

Brunner and her team’s study included 120 stroke patients with mild to severe hand weakness, all of whom were randomly assigned to add 16 hour-long therapy sessions to their routine rehabilitation over a month. One group performed physical therapy, while the other group played a virtual reality game called YouGrabber, notes a media release from HealthDay.

In the game, Brunner explains, “the patients wear gloves with sensors, and their movements are tracked by an infrared camera and transferred to a virtual arm on screen.”

“In different scenarios, they can grasp objects that come toward them or pick carrots. In other games, patients steer a plane or a car with their movement. The therapist chooses the movements to be trained and the level of difficulty.”

Fifty patients in the physical therapy group and 52 in the virtual reality group completed the study and were evaluated after 3 months.

The researchers found no difference between the two groups with regard to the improvement in their hand and arm function.

“Patients who started out with moderately to mildly impaired arm and hand motor function achieved, on average, a level of good motor function,” Brunner states, while those with severe weakness were able to use their arms to make movements.

Patients with severe hand weakness appreciated how even small movements translated to the virtual arms on screen, she adds. And even the older patients liked the virtual reality game, she notes, possibly because the graphics are simpler than those in commercial video games.

Brunner concludes by noting that larger studies are needed to understand the potential value of virtual reality as a stroke recovery treatment.

[Source: HealthDay]


via Games, Gloves, and Grip: PTs Rehab Arms and Hands Post-Stroke With YouGrabber – Rehab Managment

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[AIP Conference Proceedings] Virtual reality rehabilitation for stroke patients: Recent review and research issues.

Stroke is one of the main causes of disability in the world. In order for stroke survivors to reduce their disability, they need to go through a rehabilitation process to regain back their independence and improve their quality of life. To guide patients in their rehabilitation process and improve their receptiveness in performing repetitive exercises, a new rehabilitation training program using Virtual Reality (VR) technology has been introduced. This has attracted many researchers to explore more on VR technology as a new tool for stroke patient’s rehabilitation. This paper presents a review on existing VR systems that have been developed for stroke rehabilitation. First, recent VR systems utilized for rehabilitation after stroke are delineated and categorized. Each of these categories concludes with a discussion on limitations and any issues that arise from it. Finally, a concise summary with significant findings and future possibilities in VR rehabilitation research is presented in table format.
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[ARTICLE] Increasing upper limb training intensity in chronic stroke using embodied virtual reality: a pilot study – Full Text



Technology-mediated neurorehabilitation is suggested to enhance training intensity and therefore functional gains. Here, we used a novel virtual reality (VR) system for task-specific upper extremity training after stroke. The system offers interactive exercises integrating motor priming techniques and embodied visuomotor feedback. In this pilot study, we examined (i) rehabilitation dose and training intensity, (ii) functional improvements, and (iii) safety and tolerance when exposed to intensive VR rehabilitation.


Ten outpatient stroke survivors with chronic (>6 months) upper extremity paresis participated in a ten-session VR-based upper limb rehabilitation program (2 sessions/week).


All participants completed all sessions of the treatment. In total, they received a median of 403 min of upper limb therapy, with 290 min of effective training. Within that time, participants performed a median of 4713 goal-directed movements. Importantly, training intensity increased progressively across sessions from 13.2 to 17.3 movements per minute. Clinical measures show that despite being in the chronic phase, where recovery potential is thought to be limited, participants showed a median improvement rate of 5.3% in motor function (Fugl-Meyer Assessment for Upper Extremity; FMA-UE) post intervention compared to baseline, and of 15.4% at one-month follow-up. For three of them, this improvement was clinically significant. A significant improvement in shoulder active range of motion (AROM) was also observed at follow-up. Participants reported very low levels of pain, stress and fatigue following each session of training, indicating that the intensive VR intervention was well tolerated. No severe adverse events were reported. All participants expressed their interest in continuing the intervention at the hospital or even at home, suggesting high levels of adherence and motivation for the provided intervention.


This pilot study showed how a dedicated VR system could deliver high rehabilitation doses and, importantly, intensive training in chronic stroke survivors. FMA-UE and AROM results suggest that task-specific VR training may be beneficial for further functional recovery both in the chronic stage of stroke. Longitudinal studies with higher doses and sample sizes are required to confirm the therapy effectiveness.


Stroke affects about 17 million people per year worldwide, with an increasing rate every year [1]. Stroke survivors often suffer from physical and mental disabilities, heavily impacting their quality of life. Five years after the first stroke, nearly 66% of patients exhibit different degrees of disability and only 34% are functionally independent in their activities of daily living [2].

Motor rehabilitation after stroke

Motor dysfunction is the most prevalent impairment, with 9 out of 10 stroke survivors suffering from some form of upper limb motor disability [3], and it is a strong predictor of poor functional recovery [4]. Thus, there is a strong need for rehabilitative approaches enhancing motor recovery for stroke patients [5]. To maximize neural, motor and functional recovery, training needs to be long-lasting, challenging, repetitive, task-specific, motivating, salient, and intensive [6]. Standard motor rehabilitation after stroke typically includes neurofacilitation techniques, task-specific training and task-oriented training [7]. Further approaches include strength training, trunk restraint, somatosensory training, constraint-induced movement therapy, bilateral arm training, coordination of reach to grasp, mirror training, action observation and neuromuscular electrical stimulation [8].

Time scheduled for therapy and its frequency are determinant factors for the outcome of motor rehabilitation [9], with a recommended initial amount of at least 45 min for a minimum of 5 days per week [10]. However, the frequency of the delivered therapy usually decreases with time, with therapy being discontinued between 3 and 6 months after the vascular accident [7]. Under these rehabilitation conditions, recovery of motor function has been observed to be strongest during the first month after stroke and to slow down during subsequent months, reaching a “plateau” by 3–6 months post stroke [1112]. Clinical evidence for motor improvement in chronic stroke [13] suggests that the “plateau” may depend not only on neurobiological factors, but may also be caused by other factors such as reduction in rehabilitation services [14].

Thus, increasing therapy dose, also in the chronic phase of the disease, might be a critical factor to achieve a positive outcome. Although several guidelines for upper limb rehabilitation have been recently issued [510], the relationship between training intensity and recovery patterns is not yet fully established. Indeed, it is not fully clear how to quantify the dose increase leading to a positive outcome. Training volume, understood as the number of repetitions, seems to be a more relevant parameter of dose than just the total time allocated for therapy [9]. An important issue is how to quantify and capture this concept in a measurable parameter. Intensity of training, understood as the number of repetitions divided by the number of minutes of active therapy, might be a fundamental factor (together with amount and frequency of therapy) to quantify training efficiency. This knowledge becomes critical in order to evaluate cost-effectiveness of new technology-mediated interventions and to select the most valuable therapy procedures at the different stages of the continuum of care for stroke survivors.

Virtual reality for motor rehabilitation

Different complementary solutions have been proposed during the last decades to help increase and maintain the rehabilitation dose in the long term, mainly through continued therapy. Virtual reality (VR) based motor rehabilitation is a relatively recent approach, showing evidence of moderate effectiveness in improving upper limb and ADL function when compared to conventional therapy [15].

Many VR setups, and often generic (i.e. not developed for rehabilitation purposes) commercial off-the-shelf computer games, are used to perform a series of exercises, where patients move in front of a console and receive mostly visual feedback about their movements [161718]. This represents a limited approach, whereby the level of immersion and potential feedback is restricted to a single sensorimotor action-perception loop: the patient moves and receives only abstract visual feedback from the screen. A rather different approach implies embodied sensorimotor feedback, where movements of the patient in the real world are reproduced as movements of an anthropomorphic avatar in the virtual environment. Under such conditions, VR allows for more elaborated sensorimotor activation, which may impact the recovery process. In particular, through sensorimotor resonance mechanisms, embodied sensorimotor feedback allows the integration of motor priming techniques and cognitive principles related to body perception and action, including mirror therapy [19] and action observation [2021], which have been shown to improve functional recovery and increase cortical activation of the ipsilesional side after stroke. This embodied technology can be achieved by using motion capture technology that interprets the patient’s movements and provides multisensory (vision, audio, touch) feedback to the user about the movement performance. Such enriched VR experiences have been demonstrated to increase patients’ motivation [22] and facilitate functional recovery by engaging appropriate neural circuits in the motor system [23].

One of the VR advantages is that it enables simulated practice of functional tasks at a higher dosage than traditional therapies [15]. Lohse and colleagues recently reviewed the duration, time and frequency scheduled for different VR and computer games interventions, but training intensity (as defined above) was no reported [24]. In general, authors reported an overall median of 570 min of VR (or computer games) therapy delivered, with duration ranging from 20 to 60 min per session, and 8 to 36 sessions [24]. Otherwise, intensity of training is rarely reported for VR training (see [25] for an exception). However, this is a critical factor to estimate cost-effectiveness of VR-based interventions.

Objectives of the study

The present study aims at investigating the feasibility of admninistering intensive training in chronic stroke patients using a dedicated VR-based system that embeds real-time 3D motion capture and embodied visual feedback to deliver functional exercises designed to train impaired motor skills of the upper limb. Our primary goal was to assess (i) rehabilitation dose and training intensity in chronic patients. Additionally, we asked (ii) whether chronic stroke survivors improve functional outcomes of the upper limb when exposed to intensive VR-based therapy, and we measured (iii) safety and tolerance to such a technology-mediated intervention. We hypothesize that intensive VR-based rehabilitation may lead to high rehabilitation doses and functional improvement in chronic stroke survivors.[…]

Fig. 1a Participant performing an upper limb exercise (Grasping) with the MindMotion ™ PRO technology; b Participant doing the Reaching exercise; c Participant doing a Fruitchamp exercise


Continue —>  Increasing upper limb training intensity in chronic stroke using embodied virtual reality: a pilot study | Journal of NeuroEngineering and Rehabilitation | Full Text

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[ARTICLE] A motion intention-based upper limb rehabilitation training system to stimulate motor nerve through virtual reality – Full Text

Motor rehabilitation strategies for treating motor deficits after stroke are based on the understanding of the neural plasticity. In recent years, various upper limb rehabilitation robots have been proposed for the stroke survivors to provide relearning of motor skills by stimulating the motor nerve. However, several aspects including costing, human–robot interaction, and effective stimulation of motor nerve still remain as major issues. In this article, a new upper limb rehabilitation training system named as motion intention-based virtual reality training system is developed to close the aforementioned issues. The system identifies the user’s motion intention via force sensors mounted on the rehabilitation robot to conduct therapeutic exercises and stimulates the user’s motor nerve by introducing the illusion of immersion in virtual reality environment. The illusion of immersion is developed by creating Virtual Exoskeleton Robot model which is driven by user’s motion intention and reflecting the motion states in real time. The users can be present to the training exercises by themselves and fully engage in the virtual reality environment, so that they can relax, move, and recreate motor neuro-pathways. As preliminary phase, six healthy subjects were invited to participate in experiments. The experimental results showed that the motion intention-based virtual reality training system is effective for the upper limb rehabilitation exoskeleton and the evaluations of the developed system showed a significant reduction of the performance error in the training task.

Stroke is a major cause of acquired physical disability in adults worldwide. Motor deficits affecting the upper limb are a common manifestation of stroke and greatly contribute to decreasing the individual’s functional performance.1 It is widely appreciated that motor rehabilitation after stroke plays an essential role in reducing the individual’s physical disability.2 The rehabilitation strategies for treating motor deficits after stroke are based on the understanding of the neural plasticity which is known by the phenomenon that the human brain changes itself in response to different types of experience through the reorganization of its neuronal connections.3 To exhibit the neural plasticity, motor relearning is the most important matter because it can produce changes in synapses, neurons, and neuronal networks within specific brain regions.4 Exoskeletons are robotic systems designed to work linked with parts (or the whole) of the human body. The robotic exoskeleton structure is always maintaining contact with the human operator’s limb. It can be suitably employed in robotic-assisted rehabilitation to assist the users to proceed relearning movement training exercises. And it can also make the process of upper limb rehabilitation repeatable, with objective estimation and decrease the dependence on specialized personnel availability.

About 30 existing robotic exoskeleton devices are reviewed by Proietti et al.5 As it has been mentioned, most publications in the field of exoskeletons focused only on mechatronic design of the devices, while we do believe a paramount aspect for robots potentiality lays on the control side. So the development of innovative and improved human–robot interaction control strategies will make a certain contribution to the upper limb rehabilitation assisted by the robotic exoskeleton devices.

The virtual reality (VR) technology has been proved useful in terms of motivating and challenging patients for longer training duration and cadence, modifying patient’s participating level, and updating subjects with their training performance.6 VR-based rehabilitation protocols may significantly improve the quality of rehabilitation by offering strong functional motivations to the patient who can therefore be more attentive to the movement to be performed. VR can provide an even more stimulating video game-like rehabilitation environment when integrated with force feedback devices, thus enhancing the quality of the rehabilitation.7

An upper limb force feedback exoskeleton for robotic assisted rehabilitation in VR is presented in Frisoli et al.8 A specific VR application focused on the reaching task was developed and evaluated in the system, but the system can’t provide adjustment when the reaching is far away too much. And little details are given to the control aspects of the robotic exoskeleton. An assistive control system with a special kinematic structure of an upper limb rehabilitation robot embedded with force/torque sensors is presented by Chen et al.9 A three-dimensional (3-D) GUI system for upper limb rehabilitation using electromyography and inertia measurement unit sensor feedback is developed by Alhajjar et al.10 It encourages the patients by recording the results and providing 3-D VR arm to simulate the arm movement during the exercise. A haptic device and an inertial sensor are used to implement rehabilitation tasks proposed by Song et al.,11 the system provides the vision through the monitor and force feedback through the haptic device. Gesture therapy was presented by Sucar et al.,12 a VR-based platform for rehabilitation of the upper limb was introduced. Similarly, the patients’ use of a home-based VR system portrayed by Standen et al.13 provides a low-cost VR system that translates movements of the hand, fingers, and thumb into game play which was designed to provide a flexible and motivating approach to increasing adherence to home-based rehabilitation. It is suitable for the patients with slight independence ability, which doesn’t have to be assisted by the robotic exoskeleton.

By considering all the aforementioned limitations, motion intention-based virtual reality training system (MIVRTS) is developed by integrating motion intention identification-based upper limb therapeutic exercises and the illusion of immersion in VR. The system identifies the user’s motion intention via force sensors mounted on the rehabilitation robot to conduct therapeutic exercises and stimulates the user’s motor nerve by introducing the illusion of immersion in VR environment. The illusion of immersion is developed by creating Virtual Exoskeleton Robot model which is driven by user’s motion intention and reflecting the motion states in real time.

The rest of the article is organized as follows. “The rehabilitation robotic exoskeleton” section presents the main features of the rehabilitation robotic exoskeleton system. An overview of the developed MIVRTS system employed in this study for the validation of the exoskeleton in upper limb rehabilitation is given in “MIVRTS system” section. In “Motion intention-based application” section, the motion intention identifying method is described and an application for rehabilitation exercises is developed. “Evaluation on six participants” section explains the experiment and evaluation results, followed by conclusion described in the final section.[…]


Figure 1. 5-DOF upper limb rehabilitative exoskeleton robot. DOF: degrees of freedom.

Continue —-> A motion intention-based upper limb rehabilitation training system to stimulate motor nerve through virtual realityInternational Journal of Advanced Robotic Systems – Li Xing, Xiaofeng Wang, Jianhui Wang, 2017

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