Posts Tagged Virtual Reality

[BOOK] “Occupational Therapy – Occupation Focused Holistic Practice in Rehabilitation” – Chapter 9: Virtual Reality and Occupational Therapy


Virtual reality is three dimensional, interactive and fun way in rehabilitation. Its first known use in rehabilitation published by Max North named as “Virtual Environments and Psychological Disorders” (1994). Virtual reality uses special programmed computers, visual devices and artificial environments for the clients’ rehabilitation. Throughout technological improvements, virtual reality devices changed from therapeutic gloves to augmented reality environments. Virtual reality was being used in different rehabilitation professions such as occupational therapy, physical therapy, psychology and so on. In spite of common virtual reality approach of different professions, each profession aims different outcomes in rehabilitation. Virtual reality in occupational therapy generally focuses on hand and upper extremity functioning, cognitive rehabilitation, mental disorders, etc. Positive effects of virtual reality were mentioned in different studies, which are higher motivation than non‐simulated environments, active participation of the participants, supporting motor learning, fun environment and risk‐free environment. Additionally, virtual reality was told to be used as assessment. This chapter will focus on usage of virtual reality in occupational therapy, history and recent developments, types of virtual reality technologic equipment, pros and cons, usage for pediatric, adult and geriatric people and recent research and articles.

1. Introduction

Enhancement of functional ability and the realization of greater participation in community life are the two major goals of rehabilitation science. Improving sensory, motor, cognitive functions and practice in everyday activities and occupations to increase participation with intensive rehabilitation may define these predefined goals [1, 2]. Intervention is based primarily on the different types of purposeful activities and occupations with active participation [35]. For many injuries and disabilities, the rehabilitation process is long, and clinicians face the challenge of identifying a variety of appealing, meaningful and motivating intervention tasks that may be adapted and graded to facilitate this process [5].

Occupational therapy (OT), which is one of the rehabilitation professions, is a client‐centered profession that helps people who are suffering participation and occupational performance limitations. OT offers a wide range of rehabilitation strategies in different medical and social diagnosis [2]. The common point of all these strategies in rehabilitation is that OT assesses and supports enhancing functional ability and participation throughout participating in meaningful activities in a person’s lifespan. To enhance participation, OT, like the rest of the health professions, uses World Health Organization’s International Classification of Functioning, Disability and Health (ICF) to understand function in a biopsychosocial manner. In ICF framework, function is defined as the interactions between an individual, their health conditions and the social and personal situations in which they thrive. The complex interactions between these variables define function and disability [1].

ICF classifies health and health‐related fields in two groups. These groups are “body functions” and “body structures” and “activity and participation.” Sub heading of these groups is considered as body function and structures (physical, physiological etc), activities (daily tasks) and participation (life roles) [1]. When these groups taken into account in rehabilitation, occupational therapists focus on all areas to enhance a client’s activity participation, social participation, etc. However, in current literature, there are various rehabilitation approaches that are being used for this aim. Advancements in technology in the twenty‐first century create great opportunities for people working in different areas. In particular, in health practices like rehabilitation, technology supports therapists’ to rehabilitate their clients in too many different ways like robotics, stimulation devices, assessment tools and virtual reality [610].

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[Abstract] Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults: Prevention, Plasticity, and Participation

Use of virtual reality (VR) and serious games (SGs) interventions within rehabilitation as motivating tools for task specific training for individuals with neurological conditions are fast-developing. Within this perspective paper we use the framework of the IV STEP conference to summarize the literature on VR and SG for children and adults by three topics: Prevention; Outcomes: Body-Function-Structure, Activity and Participation; and Plasticity. Overall the literature in this area offers support for use of VR and SGs to improve body functions and to some extent activity domain outcomes. Critical analysis of clients’ goals and selective evaluation of VR and SGs are necessary to appropriately take advantage of these tools within intervention. Further research on prevention, participation, and plasticity is warranted. We offer suggestions for bridging the gap between research and practice integrating VR and SGs into physical therapist education and practice.

Source: Virtual Reality and Serious Games in Neurorehabilitation of… : Pediatric Physical Therapy

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[WEB SITE] Virtual Reality Brings Hope to Stroke Survivors

Games Technology students and Computer Science lecturers from Murdoch’s School of Engineering and Information Technology are helping stroke survivors put their lives back together.The team from Murdoch has worked with clinicians from the West Australian Neuroscience Research Institute (WANRI) to develop a computer-based Virtual Reality (VR) rehabilitation program called Neuromender, which will greatly advance the recovery of stroke survivors.

The Neuromender software captures detailed upper body data in real-time as survivors fly a ‘wing-man’ through a virtual world, with the task difficulty levels adjusted automatically by the system.

“Neuromender is a low-cost computer-based system that enables users to interact with a multisensory simulated environment in the comfort and convenience of their own home,” said Senior Lecturer and Project Leader Dr. Mohd Fairuz Shiratuddin.

Stroke is the number one cause of long-term disability in adults in Australia, effecting more than 50,000 Australians each year.


Image taken from the VR system.

Neuromender will greatly advance the recovery of stroke survivors. Credit: Murdoch University.

Currently within Australia, there are no established evidence-based VR rehabilitation programs with detailed, high resolution monitoring for the neurorehabilitation of the upper limb of stroke survivors.

As survivors use the Neuromender System, data is sent to the Neuromender’s central server, where survivors’ progress can be assessed online by Clinicians.

“Clinicians assign rehabilitative tasks to stroke survivors in their care. These tasks can be performed using any recent off the shelf sub $700 personal computer. The tasks have been specifically designed to be engaging and system is adaptive to keep the survivors’ motivation levels high,” said Shri Rai, Academic Chair of Computer Science and Games Technology.

Up to 75 per cent of stroke survivors continue to experience motor deficits associated with reduced quality of life, either as a direct result of the stroke itself or longer-term effects of disuse, inactivity and/or lifestyle changes after stroke.

“Hand and arm weakness is a common problem following stroke that substantially impacts on the quality of life of stroke survivors,” said Associate Professor Michelle Byrnes from WANRI.

“This VR rehabilitation program will have immense, positive, long-term implications for the upper rehabilitation and recovery of stroke survivors in the future.”

The motivation for developing an economical software system that could assist the rehabilitation of stroke survivors came from Dr. Shiratuddin, whose mother is a stroke survivor.

“Neuromender is designed to be extensible, and will be expanded to include more interactive and engaging contents in the near future,” he said.

About this neurology and technology research

A pilot trial is set to begin in the summer of 2016 featuring 20 stroke survivors.

Source: Luke McManus – Murdoch University
Image Credit: The image is credited to Murdoch University
Video Source: The video is available at the Murdoch University YouTube page

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[BLOG POST] Home After a Stroke: Reviewing Virtual Reality Rehab

Between September 2011 and May 2017 Dean published 173 posts about the use of virtual reality to provide rehab for stroke survivors.  The results for the hand are depressing.  For six years research focused on a subject’s ability to touch an object on the screen so the computer can move an object or make it disappear.  Enjoying these quick reactions is not enough to justify the cost of this expensive equipment.  It was a good place to start 6 years ago, but progress towards useful gains is disappointing.  Stroke survivors want to manipulate objects with their hand.

There is a glimmer of hope.  Gauthier (1) used video games that make stroke survivors do more than use their shoulder and elbow to reach forward and side to side.  These games require forearm and wrist motions.  This may not sound exciting but these motions orient our hand to the many different positions objects rest in. The photo shows the forearm is halfway between palm up and palm down so the hand can pick up a glass.  Cocking the wrist means the rim of the glass is not pointed at the ceiling but at the person’s mouth.

Unfortunately, Gauthier selected stroke survivors who already had a few degrees of active forearm and wrist movement.  How can subjects make the leap from just reaching to turning their hand palm up to catch a parachute on a video screen?  My OT gave me exercises that helped me regain forearm and wrist motions.  These small motions have made me more independent.  For example, I can turn my hand halfway between palm up and palm down to grab my cane so my sound hand can catch the door before the person in front of me lets it slam shut.  I picture stroke survivors practicing forearm and wrist motions and then immediately trying to turn their hand palm up so they can turn over a card on the computer screen. Fun + repetition is good.
1. Gauthier L, et al. Video game rehabilitation for outpatient stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis. BMC Neurology. 2017;17-109. doi:10.1186/s12883-017-0888-0.

Source: Home After a Stroke: Reviewing Virtual Reality Rehab

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[BOOK] Chapter 5: Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study – Full Text

THE BOOK:  “Physical Disabilities – Therapeutic Implications”, book edited by Uner Tan, ISBN 978-953-51-3248-6, Print ISBN 978-953-51-3247-9, Published: June 14, 2017 under CC BY 3.0 license. © The Author(s).

CHAPTER 5: By Marta Rodríguez-Hernández, Carmen Fernández-Panadero, Olga López-Martín and Begoña Polonio-López



Purpose: The aim is to present an overview of existing tools for hand rehabilitation after brain injury and a pilot study to test HandTutor® in patients with chronic brain damage (CBD).

Method: Eighteen patients with CBD have been selected to test perception on effectiveness, usability and acceptance of the device. This group is a sample of people belonging to a wider study consisting in a randomized clinical trial (RCT) that compares: (1) experimental group that received a treatment that combines the use of HandTutor® with conventional occupational therapy (COT) and (2) control group that receives only COT.

Results: Although no statistical significance has been analysed, patients report acceptance and satisfaction with the treatment, decrease of muscle tone, increase of mobility and better performance in activities of daily life. Subjective perceptions have been contrasted with objective measures of the range of motion before and after the session. Although no side effects have been observed after intervention, there has been some usability problems during setup related with putting on gloves in patients with spasticity.

Conclusions: This chapter is a step further of evaluating the acceptance of technological devices in chronic patients with CBD, but more research is needed to validate this preliminary results.

1. Introduction

According to the World Health Organization [1], cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability. The last update of the global Burden of Ischemic and Haemorrhagic Stroke [2] indicates that although age-standardized rates of stroke mortality have decreased worldwide in the past two decades, the absolute numbers of people who have a stroke every year are increasing. In 2013, there were 10.3 million of new strokes, 6.5 million deaths from stroke, almost 25.7 million stroke survivors and 113 million of people with disability-adjusted life years (DALYs) due to stroke.

One of the most frequent problems after stroke is upper limb (UL) impairments such as muscle weakness, contractures, changes in muscle tone, and other problems related to coordination of arms, hands or fingers [3, 4]. These impairments induce disabilities in common movements such as reaching, picking up or holding objects and difficult activities of daily living (ADLs) such as washing, eating or dressing, their participation in society, and their professional activities [5]. Most of people experiencing this upper limb impairment will still have problems chronically several years after the stroke. Impairment in the upper limbs is one of the most prevalent consequences of stroke. For this reason making rehabilitation is an essential step towards clinical recovery, patient empowerment and improvement of their quality of life. [6, 7].

Traditionally, therapies are usually provided to patients during their period of hospitalization by physical and occupational therapists and consist in mechanical exercises conducted by the therapists. However, in the last decades, many changes have been introduced in the rehabilitation of post-stroke patients. On the one hand, increasingly, treatments extend in time beyond the period of hospitalization and extend in the space, beyond the hospital to the patient’s home [8]. On the other hand, new agents are involved in treatments, health professionals (doctors, nurses) and non-health professionals (engineers, exercise professionals, carers and family). Most of these changes have been made possible thanks to the development of technology [9].

2. Technological devices for upper limb rehabilitation

In the last 10 years, there has been increasing interest in the use of different technological devices for upper limb (UL) rehabilitation generally [5, 9], and particularly hand rehabilitation for stroke patients [10]. These studies have approached the problem from different points of view: (1) on the one hand, by analysing the physiological and psychophysical characteristics of different devices [11], (2) on the other analysing the key aspects of design and usability [12] and (3) finally studying its effectiveness in therapy [13, 14]. According to Kuchinke [12], these technical devices can be organized into two big groups: (1) on the one hand, devices based on virtual reality (VR) and (2) on the other robotic glove-like devices (GDs).

One of the main advantage of VRs and serious games [15] is to promote task-oriented and repetitive movement training of motor skill while using a variety of stimulating environments and facilitates adherence to treatment in the long term [16]. These devices can be used at home and in most cases do not require special investment in therapeutic hardware because they can use game consumables existing at home such as Nintendo(R) Wii1 [17, 18], Leapmotion2 [19, 20] or Kinect sensor3 [21, 22]. Although first systematic studies based in VRs indicate that there is insufficient evidence to determine its effectiveness compared to conventional therapies [8], more recent studies [13, 14, 23] offer moderate evidence on the benefits of VR for UL motor improvement. Most researchers agree that VRs work well as coadjuvant to complement more conventional therapies; however, further studies with larger samples are needed to identify most suitable type of VR systems, to determine if VR results are sustained in the long term and to define the most appropriate treatment frequency and intensity using VR systems in post-stroke patients.

On the other hand, robotic systems and glove-like devices that provide extrinsic feedback like kinaesthetic and/or tactile stimulation have stronger evidence in the literature that improve motion ability of post-stroke patients [10, 24, 25]. Most of the evidences about effectiveness of GDs are based in pilot studies with non-commercial prototypes [2630], but nowadays, there are also several commercial glove-like devices that support hand rehabilitation therapies for these patients such as HandTutor® [31, 32], Music Glove [3335], Rapael Smart Glove [36] or CyberTouch [16, 37]. The main disadvantages of GDs are price, availability, because they are not yet widespread, and in some case the difficulty of setup handling and ergonomics.

As far as we know, there is little evidence in the literature supporting commercial glove-like devices for hand rehabilitation. This chapter presents a randomized clinical study (RCS) to test HandTutor® System in patients with chronic brain damage (CBD). There are some promising studies that show positive results by applying the HandTutor® in different groups of patients with stroke and traumatic brain injury (TBI) [31, 32], but samples include only people who are in the acute or subacute disease or injury but do not include chronic patients. This may be due to the added difficulty of obtaining positive results in interventions aimed at this group, in addition to the characteristics of adaptability and usability of the device that it is also harder for this kind of patients. The present work focuses on hand rehabilitation for chronic post-stroke patients.

3. Experimental design

We have conducted a pilot study (PS) to test acceptance, usability and adaptability of HandTutor® device in patients with chronic brain damage (CBD). This work describes setup, study protocol and preliminary results.

3.1. Participants description

Eligible participants met the following inclusion criteria: (1) At least 18-year age, (2) diagnosed with acquired brain injury: stroke or traumatic brain injury (TBI) and (3) chronic brain damage (more than 24 months from injury). In the final sample, 18 participants aged between 30 and 75 years old, 28% of subjects included in the pilot study are diagnosed with TBI and the remaining 72% of stroke; of these, more than half (56%) have left hemiplegia. The time from injury time exceeds 24 months, reaching 61% of cases 5 years of evolution. All the subjects included in the study attend regularly to a direct care acquired brain injury centre.

3.2. Device description

HandTutor® is a task-oriented device consistent on an ergonomic wearable glove and a laptop with rehabilitation software to enable functional training of hand, wrist and fingers. There are different models to fit both hands (left and right) and different sizes. The system allows the realization of an intensive and repetitive training but, at the same time, is flexible and adaptable to different motor abilities of patients after suffering a neurological, traumatological or rheumatological injury. The software allows the therapist to obtain different types of measures and to customize treatments for different patients, adapting the exercises to their physical and cognitive impairments. The HandTutor® provides augmented feedback and allows the participation of the user in different games that require practising their motor skills to achieve the game objective. Game objectives are highly challenging for patients and promote the improvement of deteriorated skills.

3.3. Study protocol

A randomized clinical trial (RCT) has been conducted with an experimental group and a control group. Participants in the experimental group have been treated with HandTutor® technological device, combined with conventional occupational therapy (set of functional tasks aimed at the mobility of the upper limb in ADLs). The control group only received conventional occupational therapy. All participants in the experimental group attend two weekly sessions with HandTutor®. Both groups received a weekly session of conventional therapy. It is a longitudinal study with pre-post intervention assessment, in which each subject is his control.

This chapter describes the first phase of the RCT, consisting of a pilot study (PS) to test the acceptance, usability and adaptability of the device by patients. For the PS, 18 patients of the global group were selected. Each subject completed four sessions using HandTutor® in both hands and a weekly session of COT. Each session includes quantitative and qualitative evaluation. The former one includes pre-intervention, and post-intervention assessment evaluating passive and active joint range of fingers and wrist, the latter include patients’ interviews and therapist’s observations. During the session, participants receive immediate visual and sensory feedback about their performance during exercises.

Each session includes a pre-intervention assessment and a back, wrist and hand. At the beginning of the session, the therapist evaluated the passive and active joint range of all fingers and wrist (flexion and extension). After the session, patient and therapist reviewed the increased joint range achieved during therapy on the joints involved. The software allows analysing and comparing the minimum and maximum levels in each of the movements required by the exercise. Each session lasts 45 minutes and consists of two exercises that focus their activity in flexion and extension of wrist and fingers independently, reaction speed and accuracy of the selected motion to move some elements included in the exercise.

First exercise of the session consisted in score as many balls as possible in the basket situated at the left of the patient. Every ball came to the patient from his right side. The goal of the second exercise of the session was destroying cylindrical rocks that were going from the right side to a planet situated in the left side. In both exercises, none of the elements appeared at the same height. That is why the patient had to adjust the degrees of flexion and extension of wrist, fingers or both. The occupational therapist could modify the speed, number of balls and minimum and maximum of degrees to achieve the accomplishment.

In addition to the quantitative variables described above, the therapist evaluated with qualitative methodology through interviews and observation, the condition of the skin (redness in the contact area with the glove), increased muscle tone, pain, motivation and difficulty understanding the instructions, level of usability, applicability and functionality of the patient. During the intervention, the therapist verbally corrected offsets trunk and lower limbs, annotating associated reactions in the facial muscles.

4. Results and discussion

All the participants of the experimental group completed the pilot study (n = 18). Table 1 shows the passive and active range of motion (ROM) of the preseason evaluation in fingers and wrist, divided by diagnostic (stroke vs. traumatic brain injury). Every data about ROM is shown in millimetres (average score). In the evaluation, it is noted that the hand of the participants with traumatic brain injury showed lower passive and active joints in all of the fingers (active: V: 9, IV: 10, III: 9, II: 8 and I: 10; passive: V and IV: 14, III: 11, II: 17 and I: 16), except in the wrist (stroke: active 8; passive 23 vs. traumatic brain injury: active 18; passive 20).

Stroke (average in mm) Traumatic brain injury (average in mm)
Range of motion (flexo-extension)




Active flexion deficit


Active extension deficit


Treatments sessions log
Reaction speed
Time in seconds (half)
Number of objects
Primary ranger



Table 1.

Hand ROM evaluation pre-session and treatments sessions log.

Participants with stroke show higher deficits in the flexion active of the first, second and fifth fingers (9, 5.6 and 5.6, respectively), while the extension appears more weakened in the second and third fingers (7 and 8.4, respectively). However, the participants with traumatic brain injury show higher deficit of flexion in the third finger and the extension in the second, fourth and fifth fingers.

In every session, exercises were configured with the same reaction speed and the same number of objects, to allow the participants to achieve the maximum number of hits. Some of them showed deficit of attention, which means that the speed and the increase of stimulations could decrease the final scores and the motivation of the intervention. In the case of the participants who show spasticity, this speed allows them to autorelax and control the hand between the stimulations. The length of exercises were modified according to the muscular and attentional fatigue of the participant, starting with 5 minutes and decreasing, in some cases, up to 3 minutes. All the participants reached the accuracy of movement calculated by the system, according to the preseason ROM evaluation. Also, all of them were allowed to work all of the primary movement range calculated in the evaluation.

At the beginning of the session, the occupational therapist explained the exercise to the participant and conducted a 1-minute test to check understanding. Only was necessary to provide additional verbal instruction to improve comprehension in the 11% of the cases.

Figures 1 and 2 show the ROM evaluation of the hand. In Figure 1, the active evaluation of flexion of wrist and extension of fingers is observed. Figure 2 includes the graphic representation of the millimetres of active movements (in red colour) versus the passive ones (in blue colour) of two hands with left hemiplegia (1 and 2) and two hands of participants with traumatic brain injury (tetraparesis and predominance of affectation in the right hemibody).


Figure 1.

Hand ROM evaluation (active).


Figure 2.

Hand ROM evaluation HandTutor® (passive and active).

Figures 3 and 4 display the functioning of the HandTutor® during the intervention. Figure 3 shows the glove with the hand in flexo-extension, while Figure 4 shows the assisted movement of the occupational therapist to obtain the higher ranges of flexion in a participant who shows rigidity and attentional issues. Besides, in the contralateral hand, it can be seen the associated reactions in the top member, which is not forming a part of the intervention. The hand replicates the movement that the occupational therapist is trying to get in the most affected member.


Figure 3.

Flexo-extension hand with HandTutor®.


Figure 4.

Example of assisted movement with HandTutor®.

Figures 5 and 6 show maximum and minimum scores for diagnostic. In them, it can be observed the heterogeneity of the flexion and extension movement of the participants in the study. Regarding the wrist, it is not observed huge differences by diagnostic, except in the minimum flexo-extension of the stroke group, especially in the extension. Nevertheless, the articular ranges of the fingers differ until they reach a difference of 20 millimetres in the third finger in the case of the group diagnosed with stroke, coinciding with the group diagnosed with traumatic brain injury.


Figure 5.

Flexo-extension maximum and minimum of fingers in treatments sessions log.


Figure 6.

Flexo-extension maximum and minimum of wrist in treatments session logs.

Participants referred increasing satisfaction with this new therapy. During the intervention, the software provided quantitative measures and immediate feedback of variations in patient mobility showing that HandTutor® sensors are highly sensitive to small variations in patient movement. In post-intervention interviews, patients reported that the glove decreases muscle tone of the hand and wrist, allowing ending the session with increased mobility.

All sessions evaluated qualitatively, through an interview, the following parameters: skin condition, motivation, difficulty in the understanding of instructions, level of HandTutor® utility, clinic applicability and satisfaction.

During the sessions, no side effects were observed related to the skin or post-intervention pain related with the hand use. Every participant ended the sessions without any visible injury in the skin (absence of redness, marks or changes in the coloration) and without any kind of pain. This was evaluated both at the end of the session and at the beginning of the next. To be able to contrast the information in relation with the skin condition and the pain, the data were triangulated by asking the participant and his/her primary caregiver the following day of every intervention. In both cases, they confirmed our data.

All participants referred high level of motivation and satisfaction at the end of the intervention due to the perceived higher performance of limb segments and joins involved in the exercises in their activities of daily life (ADLs). The subjective perception of the patient was checked by comparing the ROM (active vs. passive) pre-post measurement session. All participants showed and transmitted a great motivation and satisfaction with the HandTutor® intervention, except for one user. This one presents acoustic, visual and tactile hypersensitivity. After the pilot study, this participant transmitted that the glove, the sound and the images of the system induced in him/her nervousness and rejection. This information was contrasted with caregivers and professionals of the centre.

Some difficulties were found at the following of the exercise instructions, the motivation and interest maintenance during the 11% of the cases, as a consequence of the presence of attention and/or memory impairments.

All participants shared the sensation of decreasing the muscular tone, immediately at the end of every session and transmitted that this feeling stayed all day long, allowing them a higher mobility and independence at the ADLs.

During the study, some problems were observed associated with the difficulty in putting on the HandTutor® glove, especially in hands with high degrees of spasticity, mainly in diagnosed cases of traumatic brain injury (27.8%; Figure 7). Participants with lower ROM valued positively that the exercise was adapted to their possibilities, so they can reach and move objects even with their limited mobility. The 20% of the users valued negatively the weight of the system placed in the forearm, especially those with weak musculature. The occupational therapists reduced the gravity effect including a cradle to facility the placement of the forearm.


Figure 7.

Spastic hand with HandTutor®.

In those patients that showed sweating, there were placed vinyl or latex gloves on their hands to avoid direct contact with the glove.

Therefore, it seems that the HandTutor® is a device with high degrees of acceptance and usability among patients with CBD.

5. Conclusions

This chapter is a step further of evaluating the acceptance of technological devices in chronic patients with CBD. On one hand, in the theoretical part of the study, we have found in the literature strong evidence confirming the effectiveness of glove-like devices in hand rehabilitation after brain injury, but no so solid evidence of VRs effectiveness over traditional treatment. On the other hand, the practical pilot study to test HandTutor points in the expected direction confirming participants’ satisfaction about effectiveness and ergonomics of glove-like devices, but according to Ref. [12], there are still some issues to be solved in the usability of these devices for patients with spasticity.

The grade of usability of the HandTutor® device with chronic patients with CBD is high; we only find difficulties in those who show attention disorders and/or memory issues or sensorial hypersensibility. The degree of spasticity should also be taken into account in the design of the experience, because difficulties may arise in the placement of the device when the degree of spasticity is high or there is rigidity or other associated reactions.

Most of the studies performed with active gloves similar to HandTutor® device have been performed in patients in the acute or subacute phase of brain damage. It is important to emphasize that in this study, unlike the previous ones, the rehabilitation has been done with patients with more than 24 months of evolution since the diagnosis of the damage and therefore with a very high degree of chronicity in the neurological sequelae. This is one of the main contributions of the presented work since the more time has passed since the diagnosis of brain damage; the more difficult it is to achieve significant improvements with rehabilitation.

In our study, the HandTutor® device has performed effectively for the spasticity treatment in patients with CBD, producing improvements in the performance of the ADLs and elevating the motivation and satisfaction grades with his use in rehabilitation processes. However, this trial does not provide significant statistical evidence about HandTutor® effectiveness, and it would be recommendable to replicate the study with more participants to confirm our findings.

6. Acknowledgements

Work partially funded by SYMBHYO-ITC [MCINN PTQ-15-0705], RESET [MCINN TIN2014-53199-C3-1-R], eMadrid [CAM S2013/ICE-2715] and PhyMEL [UC3M 2015/00402/001] projects. Authors would like to thank Maria Pulido for their feedback in VR devices, and we also want to express our gratitude to the patients involved in the pilot study.


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14 – Viñas-Diz, S., & Sobrido-Prieto, M. (2016). Virtual reality for therapeutic purposes in stroke: A systematic review. Neurología (English Edition), 31(4): 255–277. doi:10.1016/j.nrleng.2015.06.007

15 – Joo, L. Y., Yin, T. S., Xu, D., Thia, E., Chia, P. F., Kuah, C. W. K., & He, K. K. (2010). A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. Journal of Rehabilitation Medicine 42(5): 437–441. doi:10.2340/16501977-0528

16 – Dimbwadyo-Terrer, I., Trincado-Alonso, F., de los Reyes-Guzmán, A., Aznar, M. A., Alcubilla, C., Pérez-Nombela, S., Ama-Espinosa, A., Polonio-López, B. & Gil-Agudo, Á. (2015). Upper limb rehabilitation after spinal cord injury: A treatment based on a data glove and an immersive virtual reality environment. Disability and Rehabilitation: Assistive Technology 11(6):462–467. doi:10.3109/17483107.2015.1027293

17 – Matamoros, M., Negrete, M., Haddad, Y., & Leder, R. S. (2010, March). Nintendo WII remote and Nunchuck as a wireless data subsystem for digital acquisition of analog physiologic data relevant to motor rehabilitation after stroke; part II. In 2010 Pan American Health Care Exchanges (pp. 198–200). Lima, Peru. IEEE. doi:10.1109/PAHCE.2010.5474568

18 – Adie, K., Schofield, C., Berrow, M., Wingham, J., Freeman, J., Humfryes, J., & Pritchard, C. (2014). Does the use of Nintendo Wii Sports™ improve arm function and is it acceptable to patients after stroke? Publication of the Protocol of the Trial of Wii™ in Stroke–TWIST. International Journal of General Medicine 7: 475. doi:10.2147/IJGM.S65379

19 – Eldem, C. (2014). Visual Neglect Assessment and Rehabilitation Using the Leap Motion. Saarbrücken: LAMBERT Academic Publishing

20 – Iosa, M. et al. (2015). Leap motion controlled videogame-based therapy for rehabilitation of elderly patients with subacute stroke: A feasibility pilot study. Topics in Stroke Rehabilitation 22(4): 306–316. doi:10.1179/1074935714Z.0000000036

21 – Shires, L., Battersby, S., Lewis, J., Brown, D., Sherkat, N., & Standen, P. (2013). Enhancing the tracking capabilities of the Microsoft Kinect for stroke rehabilitation. In IEEE 2nd International Conference on Serious Games and Applications for Health (SeGAH), (pp. 1–8). IEEE Portugal. doi:10.1109/SeGAH.2013.6665316

22 – Bamrungthai, P., & Pleehachinda, W. (2015, November). Development of a game-based system to support stroke rehabilitation using kinect device. In International Conference on Science and Technology (TICST), (pp. 323–326). IEEE London. doi:10.1109/TICST.2015.7369379

23 – Turolla, A., Dam, M., Ventura, L., Tonin, P., Agostini, M., Zucconi, C., & Piron, L. (2013). Virtual reality for the rehabilitation of the upper limb motor function after stroke: A prospective controlled trial. Journal of Neuroengineering and Rehabilitation 10(1): 1. doi:10.1186/1743-0003-10-85

24 – Lo, A. C., Guarino, P. D., Richards, L. G., Haselkorn, J. K., Wittenberg, G. F., Federman, D. G., Ringer R.J., Wagner T.H., Krebs H.I., Volpe B.T., Bever C.T.Jr., Bravata D.M., Duncan P.W., Corn B.H., Maffucci A.D., Nadeau S.E., Conroy S.S., Powell J.M., Huang G.D., & Peduzzi P. (2010). Robot-assisted therapy for long-term upper-limb impairment after stroke. New England Journal of Medicine 362(19): 1772–1783. doi:10.1056/NEJMoa0911341

25 – Subramanian, S. K., Massie, C. L., Malcolm, M. P., & Levin, M. F. (2010). Does provision of extrinsic feedback result in improved motor learning in the upper limb poststroke? A systematic review of the evidence. Neurorehabilitation and Neural Repair 24(2): 113–124. doi:10.1177/1545968309349941

26 – Huang, M. C., Xu, W., Su, Y., Lange, B., Chang, C. Y., & Sarrafzadeh, M. (2012). Smartglove for upper extremities rehabilitative gaming assessment. In Proceedings of the 5th International Conference on Pervasive Technologies Related to Assistive Environments (p. 20). ACM Heraklion, Crete, Greece. doi:10.1145/2413097.2413122

27 – Hiob, M. (2016). Interactive glove for mobility training and rehabilitation after stroke. Bachelor Thesis. In Certec – Rehabilitation Engineering and DesignCertec – Rehabilitation Engineering and DesignCertec – Rehabilitation Engineering and DesignCertec report TNS820 20161. Lund University Publications Student Papers. Lund, Sweden.

28 – Kang, B. B., Lee, H., In, H., Jeong, U., Chung, J., & Cho, K. J. (2016). Development of a polymer-based tendon-driven wearable robotic hand. In IEEE International Conference on Robotics and Automation (ICRA), 2016 (pp. 3750–3755). IEEE Stockholm. doi:10.1109/ICRA.2016.7487562

29 – Fischer, H. C., Triandafilou, K. M., Thielbar, K. O., Ochoa, J. M., Lazzaro, E. D., Pacholski, K. A., & Kamper, D. G. (2016). Use of a portable assistive glove to facilitate rehabilitation in stroke survivors with severe hand impairment. IEEE Transactions on Neural Systems and Rehabilitation Engineering 24(3): 344–351. doi:10.1109/TNSRE.2015.2513675

30 – Isnin, S. J., Hamid, D. H. T. A. H. & Sunar, S. Design of 3D immersive learning environment to enhanced hand skill after stroke. Man in India 96(6): 1727–1736.

31 – Carmeli, E., Vatine, J. J., Peleg, S., Bartur, G., & Elbo, E. (2009). Upper limb rehabilitation using augmented feedback: Impairment focused augmented feedback with HandTutor®. In 2009 Virtual Rehabilitation International Conference. Haifa, Israel. doi:10.1109/ICVR.2009.5174258

32 – Carmeli, E., Peleg, S., Bartur, G., Elbo, E., & Vatine, J. J. (2011). HandTutor® enhanced hand rehabilitation after stroke—A pilot study. Physiotherapy Research International 16(4): 191–200. doi:10.1002/pri.485

33 – Zondervan, D., Friedman, N. Chang, E., Zhao, X., & Cramer, S. C. (2016). Home-based hand rehabilitation after chronic stroke: Randomized, controlled single-blind trial comparing the MusicGlove with a conventional exercise program. Journal of Rehabilitation Research and Development 53(4): 457. doi:10.1682/JRRD.2015.04.0057

34 – Friedman, N., Chan, V., Zondervan, D., Bachman, M., & Reinkensmeyer, D. J. (2011, August). MusicGlove: Motivating and quantifying hand movement rehabilitation by using functional grips to play music. In 2011 Annual International Conference of the IEEE Engineering in Medicine and Biology Society (pp. 2359–2363). IEEE Boston, Massachusetts, USA doi:10.1109/IEMBS.2011.6090659

35 – Friedman, N., Chan, V., Reinkensmeyer, A. N., Beroukhim, A., Zambrano, G. J., Bachman, M., & Reinkensmeyer, D. J. (2014). Retraining and assessing hand movement after stroke using the MusicGlove: Comparison with conventional hand therapy and isometric grip training. Journal of Neuroengineering and Rehabilitation 11(1): 1. doi:10.1186/1743-0003-11-76

36 – Shin, J. H., Kim, M. Y., Lee, J. Y., Jeon, Y. J., Kim, S., Lee, S., Seo B., & Choi, Y. (2016). Effects of virtual reality-based rehabilitation on distal upper extremity function and health-related quality of life: A single-blinded, randomized controlled trial. Journal of Neuroengineering and Rehabilitation 13(1): 1. doi:10.1186/s12984-016-0125-x

37 – Kayyali, R., Shirmohammadi, S., El Saddik, A., & Lemaire, E. (2007). Daily-life exercises for haptic motor rehabilitation. In 2007 IEEE International Workshop on Haptic, Audio and Visual Environments and Games (pp. 118–123). IEEE Lyon, France.

Source: Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study | InTechOpen

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[Abstract] Effects of Virtual Reality Training using Xbox Kinect on Motor Function in Stroke Survivors: A Preliminary Study


Although the Kinect gaming system (Microsoft Corp, Redmond, WA) has been shown to be of therapeutic benefit in rehabilitation, the applicability of Kinect-based virtual reality (VR) training to improve motor function following a stroke has not been investigated. This study aimed to investigate the effects of VR training, using the Xbox Kinect-based game system, on the motor recovery of patients with chronic hemiplegic stroke.


This was a randomized controlled trial. Twenty patients with hemiplegic stroke were randomly assigned to either the intervention group or the control group. Participants in the intervention group (n = 10) received 30 minutes of conventional physical therapy plus 30 minutes of VR training using Xbox Kinect-based games, and those in the control group (n = 10) received 30 minutes of conventional physical therapy only. All interventions consisted of daily sessions for a 6-week period. All measurements using Fugl–Meyer Assessment (FMA-LE), the Berg Balance Scale (BBS), the Timed Up and Go test (TUG), and the 10-meter Walk Test (10mWT) were performed at baseline and at the end of the 6 weeks.


The scores on the FMA-LE, BBS, TUG, and 10mWT improved significantly from baseline to post intervention in both the intervention and the control groups after training. The pre-to-post difference scores on BBS, TUG, and 10mWT for the intervention group were significantly more improved than those for the control group (P <.05).


Evidence from the present study supports the use of additional VR training with the Xbox Kinect gaming system as an effective therapeutic approach for improving motor function during stroke rehabilitation.

Source: Effects of Virtual Reality Training using Xbox Kinect on Motor Function in Stroke Survivors: A Preliminary Study – Journal of Stroke and Cerebrovascular Diseases

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[Editorial] E-Rehabilitation: New Reality or Virtual Need?


This is an era of digitalization, internet, wifi, use of mobile and smart phones, virtual world, applications and technology. On one hand these are contributing to cyber psychopathology, on the other hand these have a potential for management.

With the understanding of disability as a complex interaction between the effects of illness and contextual factors, both personal and environmental, the relevance of new avenues to deliver rehabilitative services is profound. A significant proportion of the population is underserved, with the National Mental Health Survey of India 2016- a survey which covered 34,802 individuals from 12 states of India- showing a mental morbidity of 10.6% in those over the age of 18 years, and 7.3% in those between the ages of 13 and 17, but with a treatment gap of 28–83% (and 86% for alcohol use disorders). In addition, “three out of four persons with a severe mental disorder experienced significant disability in work, social and family life” [1]. Given the extent of the need and the dearth of services, the report recommends the following, “Technology based applications for near-to-home-based care using smart-phone by health workers, evidence-based (electronic) clinical decision support systems for adopting minimum levels of care by doctors, creating systems for longitudinal follow-up of affected persons to ensure continued care through electronic databases and registers can greatly help in this direction. To facilitate this, convergence with other flagship schemes such as Digital India needs to be explored” [1]. Recent data has shown that smartphone user base in India has crossed 300 million users in 2016, making it the second largest smartphone market in the world [2]. The potential for service delivery via internet enabled devices seems likely only to rise over time, but what are the possibilities before us now, and equally important, what are the challenges to such approaches?

An exploration of the role of modern technology in rehabilitation in January, 2016, has highlighted the various possibilities in terms of social networking and peer support, telepsychiatry, E health services as well as smartphones and apps [3]. It’s interesting that estimates at the time alluded to smartphone users crossing the 200 million mark in 2016, a 100 million users less than later estimates! Looking ahead these are the ways new and emerging technologies could change the ways we approach and conceptualise recovery,

  1. (a)

    Information access: Access to information and more specifically, access to relevant and accurate information have to potential to allow caregivers and patients to recognise mental health issues early, and seek help. Some of this information will be from traditional media, such as radio and television, but a significant proportion of people are likely to glean this information from social media sites and communication apps—such as the almost ubiquitous Whatsapp—on which they also consume other services and obtain their daily news and information from. Search algorithms and the way they rank different sources of information are likely to play an important role in the way people form their opinions about the illnesses they suffer from and the way they seek help. There is a need for curated information on mental health, especially in the Indian context and in vernacular languages, that people can not only refer to themselves, but which they can direct their friends and family toward as reliable sources of information too. Health care professionals must be prepared to help their patients learn ‘eHealth literacy’ [4].

  2. (b)

    Automation: Work is something that most people with mental illness aspire to do, and this can enhance their quality of life significantly [5]. Automation and applications of artificial intelligence are poised to change the face of industry as well as our lifestyles. Some traditional jobs such as fabrication and driving are poised to radically change. This will mean that vocational rehabilitation programmes will have to keep pace with a changing environment, and look to integrating industry expertise in the designing of courses and course materials which remain relevant to patients. Government programmes such as the Skill India initiative have the potential to help evolve this flexibility in course design, and to skill or re-skill persons in their quest to obtain and sustain jobs.

    Workplace is being replaced by home based workstations, computers, laptops and notebooks. People accustomed to these run their office from anywhere and everywhere. There will be a need to redefine ‘work place’ as ‘where ever the laptop is’. Thus, in future, persons undergoing rehabilitation, can ‘work from home’, provided they have the facilities, and job to do. Staying and working from home for persons with mental health problems, will prevent them from ‘live’ socialising, using social skills, and giving respite to family caregivers. On the other hand, they would be under direct supervision of the family, reducing their concerns and anxieties.

  3. (c)

    Digital identities and digital payments: With the increasing digitisation of access to services, there is a growing need for education in digital literacy and security. Programmes which teach life skills will have to help their users familiarise themselves with the advantages of new technologies as well as the risks they bring. A number of records related to disability are likely to form parts of central databases, such as the Unique Disability ID [6], and the potential to offer a number of services through a single user interface to those with disability is significant. It would also ease the accessing of such benefits even when patients travel or move to other states, whether temporarily or permanently. The storage of health records in electronic formats, e-health records, would allow patients to exert control over access to their own records and enable transfers from one healthcare provider to another without delay or loss of information. An e-health record format which is shared among different providers and which allows different hospital information systems to effectively share information is an important need. There can be a possibility to maintain a central registry of persons receiving mental health rehabilitation services.

  4. (d)

    Wearables and digital phenotyping: The mobile devices and other wearable accessories we use have the potential to collect vast amounts of information about our health. Newer approaches look to collect information such as changes in the speed of our typing or motor movements, or the searches we repeat and use these to make estimates about the status of our cognitive and neurological health in real time–an approach called digital phenotyping. This could aid in monitoring persons suffering from dementia or mild cognitive deficits. It could also be used to explore trajectories of development in children and adolescents, and could help inform early intervention programmes. Over and above monitoring, the use of digital assistants could be used to guide and shape behaviour in real time, provide cognitive aids and reduce dependency as well as the burden on caregivers for some tasks.

  5. (e)

    Virtual Reality and Augmented reality: Virtual reality (VR) refers to an interactive immersive experience wherein a computer generated world which a user can interact with is simulated with either a screen or a heads-up display. Augmented reality systems allow perception of the environment around along with the simulated projection. It’s also used to refer to situations where mobile phones or wearables can be used to interact with the environment around to either generate a virtual experience or provide additional information.

    It’s been used as an application for interventions in phobias for some time. Recent gains in the technology have coincided with an expansion of uses to cognitive rehabilitation, social skills training and even craving management in alcohol use disorders [7]. The number of mental health professionals available to deliver these services is low compared to demand and unequally distributed. With the evolution of mobile systems that can deliver VR experiences, such as the Google Daydream platform, it may be possible to translate some of these packages into content that can be delivered across such platforms with fidelity. There is still some work to be done about how perception of such experiences can affect symptoms in those with mental illness, and even if the same visual illusions are perceived differently.

  6. (f)

    Social networks, communication apps and peer support: Social networks and social media increasingly influence information access and viewpoints. They can serve as accepting communities to which people can feel as if they belong. They can also carry risks, including the spread of myths and misconceptions. Peer support groups, much like other networks, are now easier to form and to find. Hence, the potential for persons with mental illness to be involved in advocacy movements and to influence public policy is unprecedented, if still underutilised. The ability to use social networks and the internet to market products and expand networks can help those who chose to be entrepreneurs have greater reach and exposure. The ability to use these networks effectively, and other marketing skills, would also become a skill set that requires mentoring in.

  7. (g)

    The use of learning networks: Virtual classrooms and virtual learning networks have the potential to raise standards of care delivery by spreading best care practices and knowledge. Initiatives like the ECHO network and the Virtual Knowledge Network, NIMHANS can help spread the expertise of institutes by mentoring professionals who are involved in care delivery. They can also serve as ways to allow different institutes to demonstrate their own best practices and innovative models of service delivery to their peers.

The future of psychiatric practice, including psychiatric rehabilitation, in relation to virtual reality, technology and gadgets is likely to change with advances in technology and their usage [8]. While the tools that are available are changing, they will still be guided by the principles that form the bedrock of good practice in rehabilitation. Patients and their families may be drawn to online resources for rehabilitation.

The current issue of the journal is rather healthy with seventeen articles. And there is a good global distribution as well, with descriptions of mental health and rehabilitation services in Vietnam, Nigeria, USA, UK, Canada, Malaysia, and Iran. These have also covered a wide range of themes, from recovery scales, models for community based rehabilitation and community participation, in patient services, first episode psychosis, helping mothers with intellectual disabilities, and infertility. In addition, a book review on a very useful book on challenges of care giving for mental illness, cover an interesting spectrum of articles.

Source: E-Rehabilitation: New Reality or Virtual Need? | SpringerLink

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[Conference paper] Assistance System for Rehabilitation and Valuation of Motor Skills – Abstract+References


This article proposes a non-invasive system to stimulate the rehabilitation of motor skills, both of the upper limbs and lower limbs. The system contemplates two ambiances for human-computer interaction, depending on the type of motor deficiency that the patient possesses, i.e., for patients with chronic injuries, an augmented reality environment is considered, while virtual reality environments are used in people with minor injuries. In the cases mentioned, the interface allows visualizing both the routine of movements performed by the patient and the actual movement executed by him.

This information is relevant for the purpose of

  • (i) stimulating the patient during the execution of rehabilitation, and
  • (ii) evaluation of the movements made so that the therapist can diagnose the progress of the patient’s rehabilitation process.

The visual environment developed for this type of rehabilitation provides a systematic application in which the user first analyzes and generates the necessary movements in order to complete the defined task.

The results show the efficiency of the system generated by the human-computer interaction oriented to the development of motor skills.


Source: Assistance System for Rehabilitation and Valuation of Motor Skills | SpringerLink

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[Conference paper] Virtual Environments for Motor Fine Skills Rehabilitation with Force Feedback – Abstract+References


In this paper, it is proposed an application to stimulate the motor fine skills rehabilitation by using a bilateral system which allows to sense the upper limbs by ways of a device called Leap Motion. This system is implemented through a human-machine interface, which allows to visualize in a virtual environment the feedback forces sent by a hand orthosis which was printed and designed in an innovative way using NinjaFlex material, it is also commanded by four servomotors that eases the full development of the proposed tasks. The patient is involved in an assisted rehabilitation based on therapeutic exercises, which were developed in several environments and classified due to the patient’s motor degree disability. The experimental results show the efficiency of the system which is generated by the human-machine interaction, oriented to develop human fine motor skills.


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Source: Virtual Environments for Motor Fine Skills Rehabilitation with Force Feedback | SpringerLink

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[ARTICLE] The role of virtual reality in improving motor performance as revealed by EEG: a randomized clinical trial – Full Text



Many studies have demonstrated the usefulness of repetitive task practice by using robotic-assisted gait training (RAGT) devices, including Lokomat, for the treatment of lower limb paresis. Virtual reality (VR) has proved to be a valuable tool to improve neurorehabilitation training. The aim of our pilot randomized clinical trial was to understand the neurophysiological basis of motor function recovery induced by the association between RAGT (by using Lokomat device) and VR (an animated avatar in a 2D VR) by studying electroencephalographic (EEG) oscillations.


Twenty-four patients suffering from a first unilateral ischemic stroke in the chronic phase were randomized into two groups. One group performed 40 sessions of Lokomat with VR (RAGT + VR), whereas the other group underwent Lokomat without VR (RAGT-VR). The outcomes (clinical, kinematic, and EEG) were measured before and after the robotic intervention.


As compared to the RAGT-VR group, all the patients of the RAGT + VR group improved in the Rivermead Mobility Index and Tinetti Performance Oriented Mobility Assessment. Moreover, they showed stronger event-related spectral perturbations in the high-γ and β bands and larger fronto-central cortical activations in the affected hemisphere.


The robotic-based rehabilitation combined with VR in patients with chronic hemiparesis induced an improvement in gait and balance. EEG data suggest that the use of VR may entrain several brain areas (probably encompassing the mirror neuron system) involved in motor planning and learning, thus leading to an enhanced motor performance.


Virtual reality (VR) is the simulation of a real environment generated by a computer software and experienced by the user through a human–machine interface [1]. This interface enables the patient to perceive the environment as real and 3D (i.e., the sense of presence), thus increasing patient’s engagement (i.e., embodiment) [2]. Hence, VR can be used to provide the patient with repetitive, task-specific training (as opposed to simply using a limb by chance) that are effective for motor learning functions [3, 4, 5, 6]. In fact, VR provides the patient with multisensory feedbacks that can potentiate the use-dependent plasticity processes within the sensory-motor cortex, thus promoting/enhancing functional motor recovery [7, 8, 9, 10, 11, 12, 13, 14]. Furthermore, VR can increase patients’ motivation during rehabilitation by decreasing the perception of exertion [8], thus allowing patients to exercise more effortlessly and regularly [9].

It is possible to magnify the sense of presence by manipulating the characteristics of the VR, including screen size, duration of exposure, the realism of the presentation, and the use of animated avatar, i.e., a third-person view of the user that appears as a player in the VR [15]. About that, the use of an avatar may strengthen the use-dependent plastic changes within higher sensory-motor areas belonging to the mirror neuron system (MNS) [16, 17, 18]. In fact, the observation of an action, even simulated (on a screen, as in the case of VR), allows the recruitment of stored motor programs that would promote, in turn, movement execution recovery [19, 20]. These processes are expressed by wide changes in α and β oscillation magnitude at the electroencephalography (EEG) (including an α activity decrease and a β activity increase) across the brain areas putatively belonging to the MNS (including the inferior frontal gyrus, the lower part of the precentral gyrus, the rostral part of the inferior parietal lobule, and the temporal, occipital and parietal visual areas) [8, 9, 21, 22].

In the last years, motor function recovery has benefited from the use of robotic devices. In particular, robot-assisted gait training (RAGT) provides the patient with highly repeated movement execution, whose feedback, in turn, permits to boost the abovementioned use-dependent plasticity processes [23]. RAGT has been combined with VR to further improve gait in patients suffering from different neurologic diseases [24]. Nonetheless, the knowledge of the neurophysiologic substrate underpinning neurorobotic and VR interaction is still poor [25, 26]. Indeed, a better understanding of this interaction would allow physician to design more personalized rehabilitative approaches concerning the individual brain plasticity potential to be harnessed to gain functional recovery [27].

The relative suppression of the μ rhythm is considered as the main index of MNS activity [28]. Nonetheless, conjugating VR and neurorobotic could make brain dynamics more complex, because of many factors related to motor control and psychological aspects come into play, including intrinsic motivation, selective attention, goal setting, working memory, decision making, positive self-concept, and self-control. Altogether, these aspects may modify and extend the range of brain rhythms deriving from different cortical areas related to MNS activation by locomotion, including theta and gamma oscillations [29, 30, 31]. Specifically, theta activity has been related to the retrieval of stored motor memory traces, whereas the gamma may be linked to the conscious access to visual target representations [30, 31]. Such broadband involvement may be due to the recruitment of multiple brain pathways expressing both bottom-up (automatic recruitment of movement simulation) and top-down (task-driven) neural processes within the MNS implicated in locomotion recognition [32]. A recent work has shown that observed, executed, and imagined action representations are decoded from putative mirror neuron areas, including Broca’s area and ventral premotor cortex, which have a complex interplay with the traditional MNS areas generating the μ rhythm [33].

Therefore, we hypothesized that the combined use of VR and RAGT may induce a stronger and wider modification of the brain oscillations deriving from the putative MNS areas, thus augmenting locomotor function gain [34, 35]. The aim of our pilot randomized clinical trial was to understand the neurophysiological basis underpinning gait recovery induced by the observation of an animated avatar in a 2D VR while performing RAGT by studying the temporal patterns of broadband cortical activations.[…]

Continue —> The role of virtual reality in improving motor performance as revealed by EEG: a randomized clinical trial | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 5 Average changes at TPOST as compared to TPRE in scalp ERP projections relatively to the full gait cycle. The left and right hemispheres plots correspond to the affected and unaffected ones, respectively. ERS and ERD are masked in red and blue tones, respectively, whereas non-significant differences are in green (see Table 5)

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