Posts Tagged Immersive

[ARTICLE] Efficacy and Brain Imaging Correlates of an Immersive Motor Imagery BCI-Driven VR System for Upper Limb Motor Rehabilitation: A Clinical Case Report – Full Text

To maximize brain plasticity after stroke, a plethora of rehabilitation strategies have been explored. These include the use of intensive motor training, motor-imagery (MI), and action-observation (AO). Growing evidence of the positive impact of virtual reality (VR) techniques on recovery following stroke has been shown. However, most VR tools are designed to exploit active movement, and hence patients with low level of motor control cannot fully benefit from them. Consequently, the idea of directly training the central nervous system has been promoted by utilizing MI with electroencephalography (EEG)-based brain-computer interfaces (BCIs). To date, detailed information on which VR strategies lead to successful functional recovery is still largely missing and very little is known on how to optimally integrate EEG-based BCIs and VR paradigms for stroke rehabilitation. The purpose of this study was to examine the efficacy of an EEG-based BCI-VR system using a MI paradigm for post-stroke upper limb rehabilitation on functional assessments, and related changes in MI ability and brain imaging. To achieve this, a 60 years old male chronic stroke patient was recruited. The patient underwent a 3-week intervention in a clinical environment, resulting in 10 BCI-VR training sessions. The patient was assessed before and after intervention, as well as on a one-month follow-up, in terms of clinical scales and brain imaging using functional MRI (fMRI). Consistent with prior research, we found important improvements in upper extremity scores (Fugl-Meyer) and identified increases in brain activation measured by fMRI that suggest neuroplastic changes in brain motor networks. This study expands on the current body of evidence, as more data are needed on the effect of this type of interventions not only on functional improvement but also on the effect of the intervention on plasticity through brain imaging.

Introduction

Worldwide, stroke is a leading cause of adult long-term disability (Mozaffarian et al., 2015). From those who survive, an increased number is suffering with severe cognitive and motor impairments, resulting in loss of independence in their daily life such as self-care tasks and participation in social activities (Miller et al., 2010). Rehabilitation following stroke is a multidisciplinary approach to disability which focuses on recovery of independence. There is increasing evidence that chronic stoke patients maintain brain plasticity, meaning that there is still potential for additional recovery (Page et al., 2004). Traditional motor rehabilitation is applied through physical therapy and/or occupational therapy. Current approaches of motor rehabilitation include functional training, strengthening exercises, and range of movement exercises. In addition, techniques based on postural control, stages of motor learning, and movement patterns have been proposed such as in the Bobath concept and Bunnstrom approach (amongst others) (Bobath, 1990). After patients complete subacute rehabilitation programs, many still show significant upper limb motor impairment. This has important functional implications that ultimately reduce their quality of life. Therefore, alternative methods to maximize brain plasticity after stroke need to be developed.

So far, there is growing evidence that action observation (AO) (Celnik et al., 2008) and motor imagery (MI) improve motor function (Mizuguchi and Kanosue, 2017) but techniques based on this paradigm are not widespread in clinical settings. As motor recovery is a learning process, the potential of MI as a training paradigm relies on the availability of an efficient feedback system. To date, a number of studies have demonstrated the positive impact of virtual-reality (VR) based on neuroscientific grounds on recovery, with proven effectiveness in the stroke population (Bermúdez i Badia et al., 2016). However, patients with no active movement cannot benefit from current VR tools due to low range of motion, pain, fatigue, etc. (Trompetto et al., 2014). Consequently, the idea of directly training the central nervous system was promoted by establishing an alternative pathway between the user’s brain and a computer system.

This is possible by using electroencephalography (EEG)-based Brain-Computer Interfaces (BCIs), since they can provide an alternative non-muscular channel for communication and control to the external world (Wolpaw et al., 2002), while they could also provide a cost-effective solution for training (Vourvopoulos and Bermúdez, 2016b). In rehabilitation, BCIs could offer a unique tool for rehabilitation since they can stimulate neural networks through the activation of mirror neurons (Rizzolatti and Craighero, 2004) by means of action-observation (Kim et al., 2016), motor-intent and motor-imagery (Neuper et al., 2009), that could potentially lead to post-stroke motor recovery. Thus, BCIs could provide a backdoor to the activation of motor neural circuits that are not stimulated through traditional rehabilitation techniques.

In EEG-based BCI systems for motor rehabilitation, Alpha (8–12 Hz) and Beta (12–30 Hz) EEG rhythms are utilized since they are related to motor planning and execution (McFarland et al., 2000). During a motor attempt or motor imagery, the temporal pattern of the Alpha rhythms desynchronizes. This rhythm is also named Rolandic Mu-rhythm or the sensorimotor rhythm (SMR) because of its localization over the sensorimotor cortices. Mu-rhythms are considered indirect indications of functioning of the mirror neuron system and general sensorimotor activity (Kropotov, 2016). These are often detected together with Beta rhythm changes in the form of an event-related desynchronization (ERD) when a motor action is executed (Pfurtscheller and Lopes da Silva, 1999). These EEG patterns are primarily detected during task-based EEG (e.g., when the participant is actively moving or imagining movement) and they are of high importance in MI-BCIs for motor rehabilitation.

A meta-analysis of nine studies (combined N = 235, sample size variation 14 to 47) evaluated the clinical effectiveness of BCI-based rehabilitation of patients with post-stroke hemiparesis/hemiplegia and concluded that BCI technology could be effective compared to conventional treatment (Cervera et al., 2018). This included ischemic and hemorrhagic stroke in both subacute and chronic stages of stoke, between 2 to 8 weeks. Moreover, there is evidence that BCI-based rehabilitation promotes long-lasting improvements in motor function of chronic stroke patients with severe paresis (Ramos-Murguialday et al., 2019), while overall BCI’s are starting to prove their efficacy as rehabilitative technologies in patients with severe motor impairments (Chaudhary et al., 2016).

The feedback modalities used for BCI motor rehabilitation include: non-embodied simple two-dimensional tariffs on a screen (Prasad et al., 2010Mihara et al., 2013), embodied avatar representation of the patient on a screen or with augmented reality (Holper et al., 2010Pichiorri et al., 2015), neuromuscular electrical stimulation (NMES) (Kim et al., 2016Biasiucci et al., 2018). and robotic exoskeletal orthotic movement facilitation (Ramos-Murguialday et al., 2013Várkuti et al., 2013Ang et al., 2015). In addition, it has been shown that multimodal feedback lead to a significantly better performance in motor-imagery (Sollfrank et al., 2016) but also multimodal feedback combined with motor-priming, (Vourvopoulos and Bermúdez, 2016a). However, there is no evidence which modalities are more efficient in stroke rehabilitation are.

Taking into account all previous findings in the effects of multimodal feedback in MI training, the purpose of this case study is to examine the effect of the MI paradigm as a treatment for post-stroke upper limb motor dysfunction using the NeuRow BCI-VR system. This is achieved through the acquisition of clinical scales, dynamics of EEG during the BCI treatment, and brain activation as measured by functional MRI (fMRI). NeuRow is an immersive VR environment for MI-BCI training that uses an embodied avatar representation of the patient arms and haptic feedback. The combination of MI-BCIs with VR can reinforce activation of motor brain areas, by promoting the illusion of physical movement and the sense of embodiment in VR (Slater, 2017), and hence further engaging specific neural networks and mobilizing the desired neuroplastic changes. Virtual representation of body parts paves the way to include action observation during treatment. Moreover, haptic feedback is added since a combination of feedback modalities could prove to be more effective in terms of motor-learning (Sigrist et al., 2013). Therefore, the target of this system is to be used by patients with low or no levels of motor control. With this integrated BCI-VR approach, severe cases of stroke survivors may be admitted to a VR rehabilitation program, complementing traditional treatment.

Methodology

Patient Profile

In this pilot study we recruited a 60 years old male patient with left hemiparesis following cerebral infarct in the right temporoparietal region 10 months before. The participant had corrected vision through eyewear, he had 4 years of schooling and his experience with computers was reported as low. Moreover, the patient was on a low dose of diazepam (5 mg at night to help sleep), dual antiplatelet therapy, anti-hypertensive drug and metformin. Hemiparesis was associated with reduced dexterity and fine motor function; however, sensitivity was not affected. Other sequelae of the stroke included hemiparetic gait and dysarthria. Moreover, a mild cognitive impairment was identified which did not interfere with his ability to perform the BCI-VR training. The patient had no other relevant comorbidities. Finally, the patient was undergoing physiotherapy and occupational therapy at the time of recruitment and had been treated with botulinum toxin infiltration 2 months before due to focal spasticity of the biceps brachii.

Intervention Protocol

The patient underwent a 3-weeks intervention with NeuRow, resulting in 10 BCI sessions of a 15 min of exposure in VR training per session. Clinical scales, motor imagery capability assessment, and functional -together with structural- MRI data had been gathered in three time-periods: (1) before (serving as baseline), (2) shortly after the intervention and (3) one-month after the intervention (to assess the presence of long-term changes). Finally, electroencephalographic (EEG) data had been gathered during all sessions, resulting in more than 20 datasets of brain electrical activity.

The experimental protocol was designed in collaboration with the local healthcare system of Madeira, Portugal (SESARAM) and approved by the scientific and ethic committees of the Central Hospital of Funchal. Finally, written informed consent was obtained from the participant upon recruitment for participating to the study but also for the publication of the case report in accordance with the 1964 Declaration of Helsinki.

Assessment Tools

A set of clinical scales were acquired including the following:

1. Montreal Cognitive Assessment (MoCA). MoCA is a cognitive screening tool, with a score range between 0 and 30 (a score greater than 26 is considered to be normal) validated also for the Portuguese population, (Nasreddine et al., 2005).

2. Modified Ashworth scale (MAS). MAS is a 6-point rating scale for measuring spasticity. The score range is 0, 1, 1+, 2, 3, and 4 (Ansari et al., 2008).

3. Fugl-Meyer Assessment (FMA). FMA is a stroke specific scale that assesses motor function, sensation, balance, joint range of motion and joint pain. The motor domain for the upper limb has a maximum score of 66 (Fugl-Meyer et al., 1975).

4. Stroke Impact Scale (SIS). SIS is a subjective scale of the perceived stroke impact and recovery as reported by the patient, validated for the Portuguese population. The score of each domain of the questionnaire ranges from 0 to 100 (Duncan et al., 1999).

5. Vividness of Movement Imagery Questionnaire (VMIQ2). VMIQ2 is an instrument that assess the capability of the participant to perform imagined movements from external perspective (EVI), internal perspective imagined movements (IVI) and finally, kinesthetic imagery (KI) (Roberts et al., 2008).

NeuRow BCI-VR System

EEG Acquisition

For EEG data acquisition, the Enobio 8 (Neuroelectrics, Barcelona, Spain) system was used. Enobio is a wearable wireless EEG sensor with 8 EEG channels for the recording and visualization of 24-bit EEG data at 500 Hz and a triaxial accelerometer. The spatial distribution of the electrodes followed the 10–20 system configuration (Klem et al., 1999) with the following electrodes over the somatosensory and motor areas: Frontal-Central (FC5, FC6), Central (C1, C2, C3, C4), and Central-Parietal (CP5, CP6) (Figure 1A). The EEG system was connected via Bluetooth to a dedicated desktop computer, responsible for the EEG signal processing and classification, streaming the data via UDP through the Reh@Panel (RehabNet Control Panel) for controlling the virtual environment. The Reh@Panel is a free tool that acts as a middleware between multiple interfaces and virtual environments (Vourvopoulos et al., 2013).

FIGURE 1

Figure 1. Experimental setup, including: (A) the wireless EEG system; (B) the Oculus HMD, together with headphones reproducing the ambient sound from the virtual environment; (C) the vibrotactile modules supported by a custom-made table-tray, similar to the wheelchair trays used for support; (D) the visual feedback with NeuRow game. A written informed consent was obtained for the publication of this image.

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[NEWS] New Virtual Reality Therapy game could offer relief for patients with chronic pain, mobility issues

News-MedicalA 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.”

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[Abstract + References] Project Star Catcher: A Novel Immersive Virtual Reality Experience for Upper Limb Rehabilitation

Abstract

Modern immersive virtual reality experiences have the unique potential to motivate patients undergoing physical therapy for performing intensive repetitive task-based treatment and can be utilized to collect real-time user data to track adherence and compliance rates. This article reports the design and evaluation of an immersive virtual reality game using the HTC Vive for upper limb rehabilitation, titled “Project Star Catcher” (PSC), aimed at users with hemiparesis. The game mechanics were adapted from modified Constraint Induced Therapy (mCIT), an established therapy method where users are asked to use the weaker arm by physically binding the stronger arm. Our adaptation changes the physical to psychological binding by providing various types of immersive stimulation to influence the use of the weaker arm. PSC was evaluated by users with combined developmental and physical impairments as well as stroke survivors. The results suggest that we were successful in providing a motivating experience for performing mCIT as well as a cost-effective solution for real-time data capture during therapy. We conclude the article with a set of considerations for immersive virtual reality therapy game design.

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[WEB SITE] Benefits of Virtual Reality for Stroke Rehabilitation – Saebo

Virtual reality (VR) is the new must-have technology tool for gaming, training, or just trying to immerse yourself in a new and virtual environment. From Google Cardboard to Oculus Rift, this technology is becoming more and more accessible to the everyday person. Now anyone can put on a headset and suddenly be transported to a world where they have full control and no consequences.

VR technology isn’t just useful for gaming. It has been shown to help in a variety of applications, from military training activities to treatment for anxiety disorders and phobias to functioning as an art form. Another application where VR shows a lot of promise is stroke recovery.

Virtual Reality and Stroke Recovery

Virtual Reality has emerged as a new approach to treatment in stroke rehabilitation settings over the last ten years. By simulating real-life activities, stroke patients are able to work on self-care skills in a setting that is usually impossible to create in a hospital environment.

There are two main types of VR:

Immersive

In immersive VR, the virtual environment is delivered by equipment worn by the user (like goggles) or the person is situated within a virtual environment. This fully immersive system gives the user a strong sense of presence through the use of head-mounted displays, special gloves, and large, concave screen projections to create the sense of immersion.

Non-Immersive

Non-immersive VR is usually two-dimensional and delivered through a computer screen. The user can control what is happening on screen by using a device such as a joystick, mouse, or sensor.

After a stroke, mass practice, task-oriented arm training of the upper and lower limbs can help the brain “re-program” itself and form new neural connections. These new connections stimulate recovery of motor skills in patients following stroke. So VR may be useful to augment rehabilitation of the upper and lower limbs in patients suffering from stroke and other neurological injuries.

In some studies, therapists have manipulated the image onscreen to make the patient’s limb appear to be moving faster and more accurately than it was in real life. Doing this increased the patient’s confidence and made them more likely to use their affected limb spontaneously. Spontaneous use of the affected limb can help the limb recover more completely.

SaeboVR

SaeboVR is the world’s only virtual rehabilitation system exclusively focusing on ADL’s (activities of daily living). The proprietary platform was specifically designed to engage clients in both physical and cognitive challenges involving daily functional activities. In addition to interacting with meaningful every-day tasks, the SaeboVR uses a virtual assistant that appears on the screen to educate and facilitate performance by providing real-time feedback.

 

 

SaeboVR’s ADL-focused virtual world provides clients with real-life challenges. Users will incorporate their impaired upper limb to perform simulated self-care tasks that involve picking up, transferring, and manipulating virtual objects.

 

Why SaeboVR?

  • It’s the only virtual system available that focuses on real-life self-care tasks.
  • Let’s you practice repetitive movements with fun and motivating activities.
  • Activities are adaptable to the individual client to maximize success and outcomes.
  • ADL tasks can be customized to challenge endurance, speed, range of motion, coordination, timing, and cognitive demand.
  • It includes a clinical provider dashboard to view client performance and participation trends.
  • Reports are graphically displayed for easy viewing.

Saebo’s other products can also be used in conjunction with the SaeboVR to facilitate recovery. The SaeboMAS and SaeboMAS mini use unweighting technology that will allow clients with proximal weakness to participate in proven treatment techniques that would otherwise have been impossible. The SaeboGlove can engage and position the hand so it can be incorporated in virtual grasp-and-release activities.

The Future of Stroke Rehabilitation

Virtual reality is here to stay, and we have likely only scratched the surface of its medical applications. It’s having a powerful impact on those who have had strokes. Stroke survivors are taking advantage of how VR enables them to practice necessary routine activities, create new connections in the brain, and build up their confidence. With more and more survivors retraining their limbs using this technology, the future of VR in stroke recovery looks bright.

 

All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.

Source: Benefits of Virtual Reality for Stroke Rehabilitation | Saebo

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[OPINION ARTICLE] Enhancing Our Lives with Immersive Virtual Reality – Full Text

Summary

Virtual reality (VR) started about 50 years ago in a form we would recognize today [stereo head-mounted display (HMD), head tracking, computer graphics generated images] – although the hardware was completely different. In the 1980s and 1990s, VR emerged again based on a different generation of hardware (e.g., CRT displays rather than vector refresh, electromagnetic tracking instead of mechanical). This reached the attention of the public, and VR was hailed by many engineers, scientists, celebrities, and business people as the beginning of a new era, when VR would soon change the world for the better. Then, VR disappeared from public view and was rumored to be “dead.” In the intervening 25 years a huge amount of research has nevertheless been carried out across a vast range of applications – from medicine to business, from psychotherapy to industry, from sports to travel. Scientists, engineers, and people working in industry carried on with their research and applications using and exploring different forms of VR, not knowing that actually the topic had already passed away.

The purpose of this article is to survey a range of VR applications where there is some evidence for, or at least debate about, its utility, mainly based on publications in peer-reviewed journals. Of course not every type of application has been covered, nor every scientific paper (about 186,000 papers in Google Scholar): in particular, in this review we have not covered applications in psychological or medical rehabilitation. The objective is that the reader becomes aware of what has been accomplished in VR, where the evidence is weaker or stronger, and what can be done. We start in Section 1 with an outline of what VR is and the major conceptual framework used to understand what happens when people experience it – the concept of “presence.” In Section 2, we review some areas where VR has been used in science – mostly psychology and neuroscience, the area of scientific visualization, and some remarks about its use in education and surgical training. In Section 3, we discuss how VR has been used in sports and exercise. In Section 4, we survey applications in social psychology and related areas – how VR has been used to throw light on some social phenomena, and how it can be used to tackle experimentally areas that cannot be studied experimentally in real life. We conclude with how it has been used in the preservation of and access to cultural heritage. In Section 5, we present the domain of moral behavior, including an example of how it might be used to train professionals such as medical doctors when confronting serious dilemmas with patients. In Section 6, we consider how VR has been and might be used in various aspects of travel, collaboration, and industry. In Section 7, we consider mainly the use of VR in news presentation and also discuss different types of VR. In the concluding Section 8, we briefly consider new ideas that have recently emerged – an impossible task since during the short time we have written this page even newer ideas have emerged! And, we conclude with some general considerations and speculations.

Throughout and wherever possible we have stressed novel applications and approaches and how the real power of VR is not necessarily to produce a faithful reproduction of “reality” but rather that it offers the possibility to step outside of the normal bounds of reality and realize goals in a totally new and unexpected way. We hope that our article will provoke readers to think as paradigm changers, and advance VR to realize different worlds that might have a positive impact on the lives of millions of people worldwide, and maybe even help a little in saving the planet.

Continue —> Frontiers | Enhancing Our Lives with Immersive Virtual Reality | Virtual Environments

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[ARTICLE] Rehabilitation System for Stroke Patients using Mixed-Reality and Immersive User Interfaces – Full Text PDF

Abstract

The work presented in this paper addresses stroke, a disease costing the healthcare in Europe and USA over 3% of their entire healthcare expenditure, including inpatient treatments, outpatient hospital visits and long-term rehabilitation and care.

The StrokeBack project is a response to those needs offering an effective long term care and rehabilitation strategy for stroke patients, which would actively involve patients in the rehabilitation process while minimizing costly human support. The game based training system has been proposed allowing physicians to supervise the rehabilitation of patents at home. The proposed approach empowers patients and their caretakers to execute effectively rehabilitation protocols in their home settings, while leading physicians are able to monitor the rehabilitation progress remotely via Personal Health Record (PHR) system.

The increased rehabilitation speed and ability to perform training at home directly improves quality of life of patients.

more –> Full Text PDF

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