[ARTICLE] Commercial head-mounted display virtual reality for upper extremity rehabilitation in chronic stroke: a single-case design study – Full Text

Abstract

Background

Rehabilitation is crucial for maximizing recovery after stroke. Rehabilitation activities that are fun and rewarding by themselves can be more effective than those who are not. Gamification with virtual reality (VR) exploits this principle. This single-case design study probes the potential for using commercial off-the-shelf, room-scale head-mounted virtual reality for upper extremity rehabilitation in individuals with chronic stroke, the insights of which can inform further research.

Methods

A heterogeneous volunteer sample of seven participants living with stroke were recruited through advertisement. A single-case design was employed with a 5-week baseline (A), followed by a 10-week intervention (B) and a 6-month follow-up. Upper extremity motor function was assessed with validated kinematic analysis of drinking task. Activity capacity was assessed with Action Research Arm Test, Box and Block Test and ABILHAND questionnaire. Assessments were done weekly and at follow-up. Playing games on a VR-system with head-mounted display (HTC Vive) was used as rehabilitation intervention. Approximately 300 games were screened and 6 tested. Visual analysis and Tau-U statistics were used to interpret the results.

Results

Visual analysis of trend, level shift and overlap as well as Tau-U statistics indicated improvement of Action Research Arm Test in six participants. Four of these had at least a moderate Tau-U score (0.50–0.92), in at least half of the assessed outcomes. These four participants trained a total of 361 to 935 min. Two out of four participants who were able to perform the drinking task, had the highest training dose (> 900 min) and showed also improvements in kinematics. The predominant game played was Beat Saber. No serious adverse effects related to the study were observed, one participant interrupted the intervention phase due to a fall at home.

Conclusions

This first study of combining commercial games, a commercial head-mounted VR, and commercial haptic hand controls, showed promising results for upper extremity rehabilitation in individuals with chronic stroke. By being affordable yet having high production values, as well as being an easily accessible off-the-shelf product, this variant of VR technology might facilitate widespread adaption. Insights garnered in this study can facilitate the execution of future studies.

Background

Post-stroke sequelae can encompass any number of domains associated with cerebral function, including motor, sensory, language and cognitive functions. Upper extremity motor function is affected in approximately 50% of patients early after stroke [1]. About 1/3 of those with early upper extremity impairment will achieve full dexterity in the chronic stage of recovery [2] Rehabilitation is crucial for maximizing recovery from neurological conditions, including stroke. Most of the rehabilitation interventions are concentrated to the first 3 to 6 months after stroke, although the need remains for years to come [3]. Rehabilitation activities that are more engaging, e.g. virtual reality (VR), can be more effective compared to conventional rehabilitation [4, 5]. VR has been shown to improve upper extremity functioning when used in addition to conventional rehabilitation [6, 7]. A rehabilitation activity that is enjoyable can also enhance adherence and long-term use. Gaming augmented with visual and audio feedback exploits neurophysiological reward mechanisms e.g. by engaging dopaminergic reward systems, which can enhance brain plasticity [8, 9].

The VR research field is heterogeneous and has been likened to the “Wild West” [10]. VR systems within the rehabilitation context can be grouped into systems that are customized for rehabilitation [11], and those who are off-the-shelf systems for a broader entertainment market [12]. The advantage of customized systems developed for rehabilitation purposes is that they follow rehabilitation principles and can thus be intrinsically useful for rehabilitation. Commercial off-the-shelf systems on the other hand can be both more economical, entertaining as well as have a higher product quality, but in turn do require adaptation to find its place as a rehabilitation tool.

Although the layman might term only head-mounted displays (HMD) as VR, console games [13,14,15,16], 3D-monitors [17], and HMD [11, 18,19,20] are all denoted as VR within academic literature [10, 21]. On this spectrum, HMD represents the most immersive VR technology. Literature pertaining to VR, based on HMD for upper extremity stroke rehabilitation, is limited [21]. Rehabilitation approaches tested with HMD VR include both custom hardware and software [11], as well as off-the-shelf hardware with custom software [19, 20]. However, combining both off-the-shelf hardware and software seems to be unexplored ground in the field of stroke rehabilitation.

Upper extremity rehabilitation can benefit from technology that stimulate involved neurological pathways [22]. These pathways can be stimulated in room-scale HMD VR systems with haptic hand controls, where sensors track hand and head movement in 6 degrees of freedom. The market for commercial off-the-shelf room-scale VR was dominated by Oculus Rift, HTC Vive and PlayStation VR at the start of this study (early spring 2019). Among these, HTC Vive was brought to bear for this study as it was simpler to set up and use than Oculus Rift and had a far greater repertoire of games available than PlayStation VR. A monitor displays approximately what the user sees in the HMD, facilitating demonstrations by, and support from accompanying personnel.

The overall aim of this study was to explore what potential commercial off-the-shelf, head-mounted display, room-scale virtual reality has for chronic stroke rehabilitation with focus on upper extremity functioning. The results can help lay the foundations for future larger-scale studies. The study aimed also to provide further insights on which HMD-VR games can be suitable for people with chronic stroke, who might benefit most, and which outcome measures might be most suitable for evaluation.[…]

Continue

Fig.2 Screenshot of Mixed Reality footage of a participant playing Beat Saber. Mixed Reality was provided by the 3rd party software LIV, and was captured with OBS Studio

[Abstract + References] Iterative Adjustment of Stimulation Timing and Intensity During FES-Assisted Treadmill Walking for Patients After Stroke

Abstract

Functional electric stimulation (FES) is a common intervention to correct foot drop for patients after stroke. Due to the disturbances from internal time-varying muscle characteristics under electrical stimulation and external environmental uncertainties, most of the existing FES system used pre-set stimulation parameters and cannot achieve good gait performances during FES-assisted walking. Therefore, an adaptive FES control system, which used the iterative learning control to adjust the stimulation intensity based on kinematic data and a linear model to modulate the stimulation timing based on walking speed during FES-assisted treadmill walking, was designed and tested on ten patients with foot drop after stroke. In order to examine its orthotic effects, the kinematic data of the patients using the proposed control strategy were collected and compared with the data of the same patients walking using other three FES control strategies, including (1) constant pre-set stimulation intensity and timing, (2) constant pre-set stimulation intensity with speed-adaptive stimulation timing and (3) walking without FES intervention. The error between the maximum ankle dorsiflexion angle during swing phase and the target angle using the proposed control strategy was the smallest among the four conditions. Moreover, there was no significant difference in the ankle plantar flexion angle at the toe-off event and the maximum knee flexion angle during swing phase between the proposed control strategy and walking without FES. In summary, the proposed control strategy can improve FES-assisted walking performances through adaptive modulation of stimulation timing and intensity when coping with variation, and may have good potential in clinic.

References

Source

[Abstract] Responsiveness of kinematic and clinical measures of upper-limb motor function after stroke: A systematic review and meta-analysis

Abstract

Background

Kinematic analysis and clinical outcome measures with established responsiveness contribute to the quantified assessment of upper-limb function post-stroke, the selection of interventions and the differentiation of motor recovery patterns.

Objective

This systematic review and meta-analysis aimed to report trends in use and compare the responsiveness of kinematic and clinical measures in studies measuring the effectiveness of constraint-induced movement, trunk restraint and bilateral arm therapies for upper-limb function after stroke.

Methods

In this systematic review, randomised controlled trials implementing kinematic analysis and clinical outcome measures to evaluate the effects of therapies in post-stroke adults were eligible. We searched 8 electronic databases (MEDLINE, EMBASE, Web of Science, Scopus, CINAHL, CENTRAL, OTseeker and Pedro). Risk of bias was assessed according to the Cochrane Risk of Bias domains. A meta-analysis was conducted for repeated design measures of pre- and post-test data providing estimated standardised mean differences (SMDs).

Results

We included reports of 12 studies (191 participants) reporting kinematic smoothness, movement duration and efficiency, trunk and shoulder range of motion, control strategy and velocity variables in conjunction with assessment by Motor Activity Log, Fugl-Meyer Assessment and Wolf Motor Function Test. Responsiveness was higher (i.e., non-overlap of 95% confidence intervals [CIs]) for Motor Activity Log score (SMD for amount of use 1.0, 95% CI 0.75–1.25, P < 0.001; SMD for quality of movement 0.96, 95% CI 0.72–1.20, P < 0.001) than movement efficiency, trunk and shoulder range of motion, control strategy and peak velocity.

Conclusion

These results are consistent with current literature supporting the use of combined kinematic and clinical measures for comprehensive and accurate evaluation of upper-limb function post-stroke. Future research should include other design trials and rehabilitation types to confirm these findings, focusing on subgroup analysis of type of rehabilitation intervention and functional levels.

Source

[ARTICLE] Commercial head-mounted display virtual reality for upper extremity rehabilitation in chronic stroke: a single-case design study – Full Text

Abstract

Background

Rehabilitation is crucial for maximizing recovery after stroke. Rehabilitation activities that are fun and rewarding by themselves can be more effective than those who are not. Gamification with virtual reality (VR) exploits this principle. This single-case design study probes the potential for using commercial off-the-shelf, room-scale head-mounted virtual reality for upper extremity rehabilitation in individuals with chronic stroke, the insights of which can inform further research.

Methods

A heterogeneous volunteer sample of seven participants living with stroke were recruited through advertisement. A single-case design was employed with a 5-week baseline (A), followed by a 10-week intervention (B) and a 6-month follow-up. Upper extremity motor function was assessed with validated kinematic analysis of drinking task. Activity capacity was assessed with Action Research Arm Test, Box and Block Test and ABILHAND questionnaire. Assessments were done weekly and at follow-up. Playing games on a VR-system with head-mounted display (HTC Vive) was used as rehabilitation intervention. Approximately 300 games were screened and 6 tested. Visual analysis and Tau-U statistics were used to interpret the results.

Results

Visual analysis of trend, level shift and overlap as well as Tau-U statistics indicated improvement of Action Research Arm Test in six participants. Four of these had at least a moderate Tau-U score (0.50–0.92), in at least half of the assessed outcomes. These four participants trained a total of 361 to 935 min. Two out of four participants who were able to perform the drinking task, had the highest training dose (> 900 min) and showed also improvements in kinematics. The predominant game played was Beat Saber. No serious adverse effects related to the study were observed, one participant interrupted the intervention phase due to a fall at home.

Conclusions

This first study of combining commercial games, a commercial head-mounted VR, and commercial haptic hand controls, showed promising results for upper extremity rehabilitation in individuals with chronic stroke. By being affordable yet having high production values, as well as being an easily accessible off-the-shelf product, this variant of VR technology might facilitate widespread adaption. Insights garnered in this study can facilitate the execution of future studies.

Background

Post-stroke sequelae can encompass any number of domains associated with cerebral function, including motor, sensory, language and cognitive functions. Upper extremity motor function is affected in approximately 50% of patients early after stroke [1]. About 1/3 of those with early upper extremity impairment will achieve full dexterity in the chronic stage of recovery [2] Rehabilitation is crucial for maximizing recovery from neurological conditions, including stroke. Most of the rehabilitation interventions are concentrated to the first 3 to 6 months after stroke, although the need remains for years to come [3]. Rehabilitation activities that are more engaging, e.g. virtual reality (VR), can be more effective compared to conventional rehabilitation [4, 5]. VR has been shown to improve upper extremity functioning when used in addition to conventional rehabilitation [6, 7]. A rehabilitation activity that is enjoyable can also enhance adherence and long-term use. Gaming augmented with visual and audio feedback exploits neurophysiological reward mechanisms e.g. by engaging dopaminergic reward systems, which can enhance brain plasticity [8, 9].

The VR research field is heterogeneous and has been likened to the “Wild West” [10]. VR systems within the rehabilitation context can be grouped into systems that are customized for rehabilitation [11], and those who are off-the-shelf systems for a broader entertainment market [12]. The advantage of customized systems developed for rehabilitation purposes is that they follow rehabilitation principles and can thus be intrinsically useful for rehabilitation. Commercial off-the-shelf systems on the other hand can be both more economical, entertaining as well as have a higher product quality, but in turn do require adaptation to find its place as a rehabilitation tool.

Although the layman might term only head-mounted displays (HMD) as VR, console games [13,14,15,16], 3D-monitors [17], and HMD [11, 18,19,20] are all denoted as VR within academic literature [10, 21]. On this spectrum, HMD represents the most immersive VR technology. Literature pertaining to VR, based on HMD for upper extremity stroke rehabilitation, is limited [21]. Rehabilitation approaches tested with HMD VR include both custom hardware and software [11], as well as off-the-shelf hardware with custom software [19, 20]. However, combining both off-the-shelf hardware and software seems to be unexplored ground in the field of stroke rehabilitation.

Upper extremity rehabilitation can benefit from technology that stimulate involved neurological pathways [22]. These pathways can be stimulated in room-scale HMD VR systems with haptic hand controls, where sensors track hand and head movement in 6 degrees of freedom. The market for commercial off-the-shelf room-scale VR was dominated by Oculus Rift, HTC Vive and PlayStation VR at the start of this study (early spring 2019). Among these, HTC Vive was brought to bear for this study as it was simpler to set up and use than Oculus Rift and had a far greater repertoire of games available than PlayStation VR. A monitor displays approximately what the user sees in the HMD, facilitating demonstrations by, and support from accompanying personnel.

The overall aim of this study was to explore what potential commercial off-the-shelf, head-mounted display, room-scale virtual reality has for chronic stroke rehabilitation with focus on upper extremity functioning. The results can help lay the foundations for future larger-scale studies. The study aimed also to provide further insights on which HMD-VR games can be suitable for people with chronic stroke, who might benefit most, and which outcome measures might be most suitable for evaluation.[…]

Continue

Fig. 2

Screenshot of Mixed Reality footage of a participant playing Beat Saber. Mixed Reality was provided by the 3rd party software LIV, and was captured with OBS Studio