Virtual reality is a potentially important tool in patient rehabilitation and training, as well as prosthetic design.
O&P News, December 2017
Despite technological advances in prosthetics, a major problem within the O&P profession remains that a large percentage of amputees still abandon or reject their prosthesis due to lack or training or knowledge of their device, according to Ashley D. Knight, PhD.
A biomedical engineer research associate at the Center for Assistive, Rehabilitation and Robotics Technologies at the University of South Florida, Knight told O&P Newsthat untrained amputees will adjust their bodies in awkward or compensatory motions rather than reposition a joint position while performing a task with a prosthetic device. This causes misuse and improper function, which has been shown to lead to significant injuries.
However, according to Knight, one possible way to address this is by incorporating virtual reality into rehabilitation and prosthesis training.
“A successful training and rehabilitation program would allow amputees to improve their ability to perform with optimal motion and use all prosthetic control capabilities,” Knight said. “Using virtual reality for training and rehabilitation could allow for a successful controlled, individualized, progressive regime, while providing expertise care to patients both in a clinic and at home.”
Jeff Erenstone, CPO, founder and CEO of Create O&P, uses modification software in virtual reality to make digital plaster models.
Source: Gary Ziele/Create O&P.
Advanced stick figures
According to Knight, whose dissertation, “The Development of a Platform Interface with the Use of Virtual Reality to Enhance,” investigated the use of virtual reality in prosthetic training, the advantage of using virtual reality in O&P is that it allows for instant visual feedback, expertise training and motivational, immersive applications.
Knight’s dissertation, which was published in 2017 by ProQuest LLC, described the development of a “stick figure” model of the user’s motion in real-time and a character avatar animating certain motions that the patient can follow while performing rehabilitative and training tasks. Among the five participants who were unilateral transradial amputees using their own prosthetic devices, all showed improved positing, movement symmetry, joint range of motion, motivation and overall improved performance after using the virtual reality program.
“Virtual reality could allow patients to be immersed into a virtual environment while provided real-time visual feedback of their instantaneous motion, alongside an individualized predictive optimal goal motion to follow,” Knight said.
Virtually ‘endless’ advantages
According to Michael Wininger, PhD, an assistant professor of prosthetics and orthotics at the University of Hartford department of rehabilitation sciences, the potential advantages of virtual reality are endless.
“In virtual reality, you can create any setting, any environment and customize it to the patient,” he told O&P News. “You can have it be really sensitive to their specific needs, and the program can run anytime, day or night. You don’t have to feed it, and you don’t have to pay it. It’s always ready to be turned on, and it doesn’t have bad days.
Virtual reality, as well as augmented reality, has become more popular in teaching and clinical settings in the last 15 years, Wininger said. He added that researchers have found that rehabilitation and training with virtual reality can result in improved outcomes for patients compared to the current training and rehabilitation paradigm.
This has been recognized in the past with regard to stroke rehabilitation. However, it has more recently been implemented in O&P settings, he said.
“If you have someone who has a stroke and they can’t use their affected limb well and you present them with a conventional clinical test, it’s up to the clinician to get as much as they can from the patient,” he said. “However, with virtual reality, the clinician can encourage the patient to engage with the virtual environment — they want to grab a ball or score a point, and it becomes more satisfying. People are inherently interested in playing games and getting the high score.”
An amputee performs a rehabilitative training task on the Computer Assisted Rehabilitation Environment system at the Center for Assistive Rehabilitation and Robotics Technology Lab at the University of South Florida, with the optimal model shown on the right as the character avatar and the real-time model shown on the left as the white stick figure.
Source: Ashley D. Knight/Center for Assistive Rehabilitation and Robotics Technology Lab, University of South Florida.
Using virtual reality, patients can see themselves in a brand-new space, with the room transformed around them into something exotic or engaging, Wininger said. Such immersive environments can in turn help the patient become more interested in training. According to Wininger, if clinicians can convince patients to complete a task when they are inside the clinic or when they are in a virtual training environment, they are more likely to be able to accomplish that same task once they have left the clinic or that training environment.
“The old adage is, ‘If you don’t use it, you lose it,’” Wininger said. “It’s about developing skills in a setting that they can translate into actual activities in their daily living. If they don’t practice it, then they are never going to use it in the real world.”
Virtual reality can also make rehabilitation more accessible for patients.
As an example, Wininger pointed to the Nintendo video game Pokémon Go, which uses augmented reality to allow players to “catch” monsters that appear to populate the real world. According to Wininger, the game shows that children, teens and young adults are open to such virtual or augmented experiences, and could be more willing to use similar technologies in rehabilitation and prosthetic training.
“Kids know this stuff and they want this stuff,” he said. “It also makes it more accessible because they can just bring it home. You don’t have to schlep all this equipment to the clinic on a snowy day. You can just turn on your virtual reality system and do it at home — and they should, because research shows that regular exposure to your training program improves your outcomes. Doing it multiple times a week is not effective, but multiple times a day will improve outcomes.”
Clinicians and their young patients stand to gain tremendously if they can find a way to incorporate virtual gaming into their prosthetic rehabilitation program, Wininger added, as it could boost participation.
“Suddenly you have people who could not play games, playing games,” he said. “It could make an inroad for them.”
Virtual design, digital fabrication
In June 2017, 3-D printer supplier Create O&P, announced the development of a new software platform that uses virtual reality and 3-D printing to allow clinicians to design, print and test fit a prosthesis in less than 3 hours.
Clinicians who use the system are able to scan a patient and upload the image to a smartphone. Then, using a virtual reality headset, they can modify a digital mold by hand in the virtual world, the company said. The clinician can design a test socket around the digital mold and send it to a 3-D printer for fabrication.
According to Jeff Erenstone, CPO, founder and CEO of Create O&P, the company uses the Google Daydream, a virtual reality headset that interfaces with the user’s smartphone. The headset can cost as little as $60. Unlike other virtual reality systems that require large amounts of computing power, the Daydream uses a smartphone, which has the additional benefit of increasing mobility, Erenstone said.
“It’s used for the modifications on the amputee’s limb, making digital plaster models,” he said. “Usually in O&P, you would take a cast, make a plaster model from that, modify the shape to get the right clinical set to make the socket and get the right prosthetic leg or arms. In our office, we are doing, from start to finish, check sockets in 3 hours consistently, and that involves 15 minutes on a computer, the printer prints it in about 2.5 hours, and then there is 10 minutes of post processing. Aside from that 15 minutes on the computer, it’s a completely hands-free process, so no technician is running around to get that done.”
According to Erenstone, that represents a huge gain in man-power efficiency, both in terms of the practitioner and the technician. The technician can then focus on more complex things “instead of just pouring plaster,” he added.
However, even with its advantages, the transition to virtual reality can be awkward for technicians who are used to working with solid objects. For that reason, Erenstone, who is also the owner and head clinician of Mountain Orthotics and Prosthetics, said his companies use touch screens along with the virtual reality technology, to simulate a certain degree of “pushback.”
“It’s weird — you don’t get the haptic feedback,” he said. “That’s why we’ve been using the touch screen technology, so you can feel your fingers pushing back on something. Meanwhile, with virtual reality, you are sort of just waving your hands in the air. Adding haptic feedback would be huge, so you could actually push back against something.”
According to Erenstone, the hardest part of convincing clinicians and technicians to use the software is the idea of no longer working with one’s hands and performing the physical manipulation of a plaster model.
“So, we’ve been working on intuitive ways to transfer the skillset they already have and have them be able to, without a big paradigm shift, use this digital technology,” he added.
Despite its promise, virtual reality, as the technology currently stands, is not without drawbacks.
According to Erenstone, the lack of a haptic response is one of them.
“There is still kind of a software lag, where it’s not as efficient as we need to be yet, but that is just the virtual reality aspect of it,” Erenstone said. “However, in 6 months that issue may be resolved, based on the way technology moves. In the past, you would need an $800 virtual reality system and need to plug it into something with serious computing power to access these systems. Now, it can be cellphone based, and browser based and now they are writing programs that can build on that.”
According to Knight, there is limited knowledge of virtual reality currently in O&P, which could result in insufficient training.
“There are a limited number of specialists and expertise in the field, especially when considering upperextremity prostheses, resulting in amputees not having sufficient training with their device,” Knight said.
Another issue with the current state of virtual reality technology is that it is not known exactly how to design and interface with the program with the highest efficiency. According to Wininger, the best virtual reality systems available today still require supervision by humans, even as it adapts to the patient’s needs.
“The problem is that the intelligence for these software packages is not where we need it to be yet, so it still requires a lot of management,” Wininger said. “And if you present something to a patient that is suboptimal, they may get discouraged and throw it away and decide not to use it. That way, you have lost on your investment, and virtual reality is currently not cheap.”
According to Wininger, the most significant issue with virtual reality is that developers still do not yet know exactly how to design or harness virtual reality for maximum efficacy.
“Therefore, there are less opportunities to improve our game there,” he said. “I would say that, in 10 years, the statisticians will have caught up to software designers to address this issue, but we’re not there yet.”
Future, fun and games
According to Wininger, the true driver of virtual reality technology is currently the gaming market, due to its deep pockets and active development scene. However, he foresees O&P “catching up to gaming” in the coming years.
“In the short-term, we will eventually see a situation in which innovations in virtual reality that come out in the gaming world will soon after become available for use in O&P,” Wininger said. “After that, anything that the gaming folks come up with, we in O&P can then use, and then we can work in lockstep with them. We’re almost there now.”
In rare instances, Wininger said O&P could develop technologies that could eventually be appropriated by the gaming industry.
“Prosthetics is all about controlling one thing with something else,” he said. “I can see some applications where gamers may be interested in taking prosthetic systems and even using them in a game.”
According to Knight, the future of virtual reality in O&P should include small-scale, adaptable options for rehabilitation practitioners. She added that widespread at-home use could successfully provide effective training and rehabilitative care to patients.
Virtual reality technology also has the potential to affect the future of the developing world, according to Erenstone. The continued development of mobile-based virtual reality will help residents and researchers in developing countries to more easily take advantage of the technology, he added.
“In the United States, we can buy a laptop with a touchscreen, but in the developing world, that is a specialty device and another piece of hardware they have to buy,” he said. “Meanwhile, everyone has a cellphone. I’ve been to Haiti, Nepal and India, and everyone has a cellphone, partly because they don’t have the infrastructure for landlines. We would be using the technology that they already have.” – by Jason Laday
Disclosures: Erenstone reports employment with Create O&P and Mountain Orthotics and Prosthetics. Knight and Wininger report no relevant financial disclosures
via O&P’s Virtual Present and Future