[Abstract] Evaluation of custom-made VR exergame for at-home Stroke rehabilitation. A longitudinal single-arm study. – Full Text PDF

Abstract

Exercise games (Exergames) based on Virtual Reality (VR) have emerged as a promising option for supporting physical rehabilitation in stroke users. As a com- plementary therapy, they offer valuable benefits such as therapy engagement and enjoyment. In this study, we assessed the effectiveness of an immersive, custom- made VR exergame designed for upper limb rehabilitation in stroke participants aged 50 and above. We conducted 14 sessions of 15 minutes involving ten par- ticipants (6 females, ages 58.1 ± 7.5 years old) who volunteered to participate in an assisted at-home rehabilitation process. The study employed a range of evaluation tests to measure physical rehabilitation and game user experience out- comes. The tests included pre- and post-assessments of range of motion (ROM), the Ashworth spasticity test, and the Borg rating of perceived fatigue question- naire. To evaluate the game participant experience, we used the VR Neuroscience Questionnaire (VRNQ), and the Immersive Tendencies Questionnaire (ITQ). Our results revealed significant improvements in the range of motion for elbow and shoulder flexion, extension, adduction, and abduction. Furthermore, we observed a reduction in Ashworth spasticity, and the fatigue scale showed reduced per- ception comparing the last with the first session, although the difference was insignificant. The VRNQ questionnaire indicated significant enhancements in the domains related to ”Game Experience” and ”Game Mechanics” and an overall reduction of the perceived “Motion Sickness”. In the ITQ questionnaire, partic- ipants reported high levels of ”Attention,” and while there were no significant differences in ”Immersion” and ”Enjoyment,” a considerable improvement was observed in ”Excitement”. In summary, our results indicate that the immersive VR exergame improved the range of motion, spasticity, and overall game user experience among participants with stroke in a longitudinal, single-arm inter- vention. We conclude that using custom-made VR exergames is an effective and motivating tool for upper limb rehabilitation, with positive changes in both clin- ical and perception outcomes, and the positive and measurable effects persist after the first sessions. These findings support using VR exergames as a comple- mentary tool for at-home rehabilitation therapy with good ease of use, improved physical rehabilitation outcomes, and high treatment adherence.

Source

[Abstract] Evaluation of custom-made VR exergame for at-home Stroke rehabilitation. A longitudinal single-arm study. – Full Text PDF

Abstract

Exercise games (Exergames) based on Virtual Reality (VR) have emerged as a promising option for supporting physical rehabilitation in stroke users. As a com- plementary therapy, they offer valuable benefits such as therapy engagement and enjoyment. In this study, we assessed the effectiveness of an immersive, custom- made VR exergame designed for upper limb rehabilitation in stroke participants aged 50 and above. We conducted 14 sessions of 15 minutes involving ten par- ticipants (6 females, ages 58.1 ± 7.5 years old) who volunteered to participate in an assisted at-home rehabilitation process. The study employed a range of evaluation tests to measure physical rehabilitation and game user experience out- comes. The tests included pre- and post-assessments of range of motion (ROM), the Ashworth spasticity test, and the Borg rating of perceived fatigue question- naire. To evaluate the game participant experience, we used the VR Neuroscience Questionnaire (VRNQ), and the Immersive Tendencies Questionnaire (ITQ). Our results revealed significant improvements in the range of motion for elbow and shoulder flexion, extension, adduction, and abduction. Furthermore, we observed a reduction in Ashworth spasticity, and the fatigue scale showed reduced per- ception comparing the last with the first session, although the difference was insignificant. The VRNQ questionnaire indicated significant enhancements in the domains related to ”Game Experience” and ”Game Mechanics” and an overall reduction of the perceived “Motion Sickness”. In the ITQ questionnaire, partic- ipants reported high levels of ”Attention,” and while there were no significant differences in ”Immersion” and ”Enjoyment,” a considerable improvement was observed in ”Excitement”. In summary, our results indicate that the immersive VR exergame improved the range of motion, spasticity, and overall game user experience among participants with stroke in a longitudinal, single-arm inter- vention. We conclude that using custom-made VR exergames is an effective and motivating tool for upper limb rehabilitation, with positive changes in both clin- ical and perception outcomes, and the positive and measurable effects persist after the first sessions. These findings support using VR exergames as a comple- mentary tool for at-home rehabilitation therapy with good ease of use, improved physical rehabilitation outcomes, and high treatment adherence.

Source

[WEB] Music Therapy and Virtual Reality Boost Post-Stroke Function

Studies show music therapy and virtual reality reverse “neurologic neglect.”

KEY POINTS

• “Neglect” is a neurological disorder impacting stroke survivors’ motor skills and critical perceptual domains.
• Several studies show improved task performance and brain activity through music therapy and VR interventions.
• Music therapy combined with virtual reality may be a more engaging neglect rehabilitation approach.

By Andrew Danso, Ph.D.

Did you know that after a stroke, nearly one-third of survivors face a challenging condition known as “neglect”? This neurological disorder significantly impacts a stroke survivor’s rehabilitation, affecting their motor skills and critical perceptual domains, such as spatial awareness.

Visuospatial neglect (VSN) is particularly notable, where patients struggle to identify objects in areas of their visual field, often on their left side (though not exclusively). This often leads to increased risks of falls and heightened caregiver stress.

Traditional rehabilitation can be tough on both patients and therapists, leading to issues with patient and diagnostic challenges for therapists. The lack of a standardised treatment for VSN and neglect exacerbates this issue, leading to recent research efforts focused on developing treatment solutions.

Two recent studies (study 1 and study 2) have pointed out the promise of using music therapy and virtual reality (VR) as potential treatment experiences for VSN patients.

In music therapy, a practice known as Musical Neglect Training (MNT) involves patients actively participating in musical exercises. In these exercises, patients are instructed to play musical patterns (that can be melodic or rhythmic) on different musical instruments, which extend to the neglected visual field (commonly their left side, but not exclusively). A music therapy study showed promising findings in this area.

article continues after advertisement

VR has also shown promise in this area. Recent studies have demonstrated its effectiveness in the diagnosis and assessment of VSN, as well as in motivation. The studies highlight core advantages of VR treatment for VSN, including

• Customisable treatment experiences
• Immersive patient experiences

User testing the virtual reality application

Additionally, a research team found evidence of an increase in brain activity regions of neglect patients after using a VR intervention, linked to improvements in their saccadic eye movements—a rapid eye glance from one point to another.

A recent study attempted to combine a MNT and VR intervention. The initial findings of this combined approach were promising. Across various patient measures, patients showed varied results in engagement and response. A few patients reported improvements in task performance, suggesting a VR and MNT combined exercise could positively impact rehabilitation. Another study currently in peer review found promising results in VSN patients’ engagement and positive feedback while using a custom-made VR application for treatment. In addition, they found one patient’s task response time might have improved considerably with the use of audio cues.

These studies provide glimpses into the future of tailored rehabilitation and are promising in the ongoing development of rehabilitation treatments for stroke and neglect.

Andrew Danso, Ph.D., is a postdoctoral researcher at the Music Therapy, Centre of Excellence in Music, Mind, Body and Brain, University of Jyväskylä, Finland.

References

Danso, A., Leandertz, M., Ala-Ruona, E., & Rousi, R. (2022). Neglect, Virtual Reality and Music Therapy: A Narrative Review. Music and Medicine, 14(3).

Danso, A., Nijhuis, P., Ansani, A., Hartmann, M., Minkkinen, G., Luck, G., Bamford, J.S., Faber, S., Agres, K.R., Glasser, S., Särkämö, T., Rousi, R., & Thompson, M. R. (2023). Virtual Reality-Assisted Physiotherapy for Visuospatial Neglect Rehabilitation: A Proof-of-Concept Study. arXiv preprint arXiv:2312.12399.

Ekman, U., Fordell, H., Eriksson, J., Lenfeldt, N., Wåhlin, A., Eklund, A., & Malm, J. (2018). Increase of frontal neuronal activity in chronic neglect after training in virtual reality. Acta Neurologica Scandinavica, 138(4), 284–292.

Heyse, J., Carlier, S., Verhelst, E., Vander Linden, C., De Backere, F., & De Turck, F. (2022). From Patient to Musician: A Multi-Sensory Virtual Reality Rehabilitation Tool for Spatial Neglect. Applied Sciences, 12(3), 1242–1242.

Kang, K., & Thaut, M. H. (2019). Musical neglect training for chronic persistent unilateral visual neglect post-stroke. Frontiers in Neurology, 10, 474.

Moon, H.-S., Shin, S.-W., Chung, S.-T., & Kim, E. (2019). K-CBS-based unilateral spatial neglect rehabilitation training contents utilizing virtual reality. 1–3.

Schwab, P. J., Miller, A., Raphail, A.-M., Levine, A., Haslam, C., Coslett, H. B., & Hamilton, R. H. (2021). Virtual Reality Tools for Assessing Unilateral Spatial Neglect: A Novel Opportunity for Data Collection. Journal of Visualized Experiments, 169.

Wagner, S., Preim, B., Saalfeld, P., & Belger, J. (2019). Crossing iVRoad: A VR application for detecting unilateral visuospatial neglect in poststroke patients. 1–2.Morereferences

Source

[Abstract + References] Combined noninvasive brain stimulation virtual reality for upper limb rehabilitation poststroke: A systematic review of randomized controlled trials

Abstract

Upper limb impairments are common consequences of stroke. Noninvasive brain stimulation (NIBS) and virtual reality (VR) play crucial roles in improving upper limb function poststroke. This review aims to evaluate the effects of combined NIBS and VR interventions on upper limb function post-stroke and to provide recommendations for future studies in the rehabilitation field. PubMed, MEDLINE, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched from inception to November 2023. Randomized controlled trials (RCTs) encompassed patients with a confirmed stroke diagnosis, administrated combined NIBS and VR compared with passive (i.e., rest) or active (conventional therapy), and included at least one outcome assessing upper limb function (i.e., strength, spasticity, function) were selected. The quality of the included studies was assessed using the Cochrane Collaboration tool. Seven studies met the eligibility criteria. In total, 303 stroke survivors (Mean age: 61.74 years) were included in this review. According to the Cochrane Collaboration tool, five studies were classified as “high quality,” while two were categorized as “moderate quality”. There are mixed findings for the effects of combined NIBS and VR on upper limb function in stroke survivors. The evidence for the effects of combined transcranial direct current stimulation and VR on upper limb function post-stroke is promising. However, the evidence regarding the effects of combined repetitive transcranial magnetic stimulation and VR on upper limb function is limited. Further randomized controlled trials with long-term follow-up are strongly warranted.

References

1. Mortality and global health estimates (2019) Who.int. https://www.who.int/data/gho/data/themes/topics/topicdetails/GHO/gho-ghe-mortality-and-global-health-estimates
2. Buma FE, Kwakkel G, Ramsey NF (2013) Understanding upper limb recovery after stroke. Restor Neurol Neurosci 31(6):707–722. https://doi.org/10.3233/rnn-130332Article PubMed Google Scholar 
3. Miller EL, Murray L, Richards L, Zorowitz RD, Bakas T, Clark PC, Billinger SA (2010) Comprehensive Overview of Nursing and interdisciplinary Rehabilitation care of the stroke patient. Stroke 41(10):2402–2448. https://doi.org/10.1161/str.0b013e3181e7512bArticle PubMed Google Scholar 
4. Kwakkel G, Kollen BJ (2012) Predicting Activities after Stroke: What is Clinically Relevant? Int J Stroke 8(1):25–32. https://doi.org/10.1111/j.1747-4949.2012.00967.xArticle Google Scholar 
5. Pollock A, Farmer SE, Brady M, Langhorne P, Mead G, Mehrholz J, Van Wijck F (2014) Interventions for improving upper limb function after stroke. Cochrane Libr. https://doi.org/10.1002/14651858.cd010820.pub2Article Google Scholar 
6. Cassidy JM, Cramer SC (2016) Spontaneous and Therapeutic-Induced Mechanisms of functional recovery after Stroke. Transl Stroke Res 8(1):33–46. https://doi.org/10.1007/s12975-016-0467-5Article PubMed PubMed Central CAS Google Scholar 
7. Warraich Z, Kleim JA (2010) Neural plasticity: the biological substrate for neurorehabilitation. PM&R 2(12S). https://doi.org/10.1016/j.pmrj.2010.10.016
8. Kleim JA, Jones TA (2008) Principles of Experience-Dependent Neural Plasticity: Implications for rehabilitation after Brain damage. Journal of Speech Language and Hearing Research 51(1). https://doi.org/10.1044/1092-4388(2008/018
9. Subramanian S, Lourenço CB, Chilingaryan G, Sveistrup H, Levin MF (2012) Arm motor recovery using a virtual reality intervention in chronic stroke. Neurorehabil Neural Repair 27(1):13–23. https://doi.org/10.1177/1545968312449695Article PubMed Google Scholar 
10. Alashram AR, Padua E, Aburub A, Raju M, Annino G (2022) Transcranial direct current stimulation for upper extremity spasticity rehabilitation in stroke survivors: A systematic review of randomized controlled trials. PM&R 15(2):222–234. https://doi.org/10.1002/pmrj.12804Article Google Scholar 
11. Sherman WR, Craig AB (2003) Understanding Virtual Reality—Interface, application, and design. Presence: Teleoperators Virtual Environ 12(4):441–442Article Google Scholar 
12. Sveistrup H (2004) Motor rehabilitation using virtual reality. J Neuroeng Rehabil 1(1):1–10. https://doi.org/10.1186/1743-0003-1-10Article Google Scholar 
13. Saleh S, Fluet GG, Qiu Q, Merians AS, Adamovich SV, Tunik E (2017) Neural Patterns of Reorganization after Intensive Robot-Assisted Virtual Reality Therapy and Repetitive Task Practice in Patients with Chronic Stroke. Frontiers in Neurology 8. https://doi.org/10.3389/fneur.2017.00452
14. Alashram AR, Annino G, Padua E, Romagnoli C, Mercuri NB (2019) Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology. J Clin Neurosci 66:209–219. https://doi.org/10.1016/j.jocn.2019.04.026Article PubMed Google Scholar 
15. Chi B, Chau B, Yeo E, Ta P (2019) Virtual reality for spinal cord injury-associated neuropathic pain: Systematic review. Ann Phys Rehabil Med 62(1):49–57. https://doi.org/10.1016/j.rehab.2018.09.006Article PubMed CAS Google Scholar 
16. Alashram AR, Padua E, Annino G (2022) Virtual reality for balance and mobility rehabilitation following traumatic brain injury: A systematic review of randomized controlled trials. J Clin Neurosci 105:115–121. https://doi.org/10.1016/j.jocn.2022.09.012Article PubMed Google Scholar 
17. Alashram AR, Padua E, Hammash AK, Lombardo M, Annino G (2020) Effectiveness of virtual reality on balance ability in individuals with incomplete spinal cord injury: A systematic review. J Clin Neurosci 72:322–327. https://doi.org/10.1016/j.jocn.2020.01.037Article PubMed Google Scholar 
18. Teasell R, Mehta S, Pereira S, McIntyre A, Janzen S, Allen L, Lobo L, Viana R (2012) Time to rethink Long-Term rehabilitation management of stroke patients. Top Stroke Rehabil 19(6):457–462. https://doi.org/10.1310/tsr1906-457Article PubMed Google Scholar 
19. Alashram AR, Padua E, Annino G (2022) Noninvasive brain stimulation for cognitive rehabilitation following traumatic brain injury: a systematic review. Appl Neuropsychol Adult 30(6):814–829. https://doi.org/10.1080/23279095.2022.2091440Article PubMed Google Scholar 
20. Alashram AR, Padua E, Romagnoli C, Raju M, Annino G (2021) Effects of Repetitive transcranial magnetic stimulation on Upper extremity spasticity Post-Stroke: A Systematic review. Physikalische Medizin Rehabilitationsmedizin Kurortmedizin. https://doi.org/10.1055/a-1691-9641Article Google Scholar 
21. Schlemm E, Schulz R, Bönstrup M, Krawinkel L, Fiehler J, Gerloff C, Thomalla G, Cheng B (2020) Structural brain networks and functional motor outcome after stroke—a prospective cohort study. Brain Communications 2(1). https://doi.org/10.1093/braincomms/fcaa001
22. Hara T, Shanmugalingam A, McIntyre A, Burhan AM (2021) The Effect of Non-Invasive Brain Stimulation (NIBS) on attention and Memory Function in Stroke Rehabilitation Patients: A Systematic Review and Meta-Analysis. Diagnostics 11(2):227. https://doi.org/10.3390/diagnostics11020227Article PubMed PubMed Central Google Scholar 
23. Dhaliwal SK, Meek BP, Modirrousta M (2015) Non-Invasive brain stimulation for the treatment of symptoms following traumatic brain injury. Frontiers in Psychiatry 6. https://doi.org/10.3389/fpsyt.2015.00119
24. Rossi S, Hallett M, Rossini PM, Pascual-Leone Á (2009) Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol 120(12):2008–2039. https://doi.org/10.1016/j.clinph.2009.08.016Article PubMed PubMed Central Google Scholar 
25. Tassinari CA, Cincotta M, Zaccara G, Michelucci R (2003) Transcranial magnetic stimulation and epilepsy. Clin Neurophysiol 114(5):777–798. https://doi.org/10.1016/s1388-2457(03)00004-xArticle PubMed Google Scholar 
26. Sandrini M, Umiltà C, Rusconi E (2011) The use of transcranial magnetic stimulation in cognitive neuroscience: A new synthesis of methodological issues. Neurosci Biobehav Rev 35(3):516–536. https://doi.org/10.1016/j.neubiorev.2010.06.005Article PubMed Google Scholar 
27. Peinemann A, Reimer B, Löer C, Quartarone A, Münchau A, Conrad B, Siebner HR (2004) Long-lasting increase in corticospinal excitability after 1800 pulses of subthreshold 5 Hz repetitive TMS to the primary motor cortex. Clin Neurophysiol 115(7):1519–1526. https://doi.org/10.1016/j.clinph.2004.02.005Article PubMed Google Scholar 
28. Mansur CG, Fregni F, Boggio PS, Riberto M, Neto JG, Santos CMD, Wagner T, Rigonatti SP, Marcolin MA, Pascual-Leone A (2005) A sham stimulation-controlled trial of rTMS of the unaffected hemisphere in stroke patients. Neurology 64(10):1802–1804. https://doi.org/10.1212/01.wnl.0000161839.38079.92Article PubMed CAS Google Scholar 
29. Huang Y, Edwards MJ, Rounis E, Rothwell JC (2007) Theta burst stimulation on human motor cortex. Clin Neurophysiol 118(5):e151. https://doi.org/10.1016/j.clinph.2006.07.224Article Google Scholar 
30. Schicktanz N, Fastenrath M, Milnik A, Spalek K, Auschra B, Nyffeler T, Papassotiropoulos A, De Quervain DJ, Schwegler K (2015) Continuous Theta Burst Stimulation over the Left Dorsolateral Prefrontal Cortex Decreases Medium Load Working Memory Performance in Healthy Humans. PLOS ONE 10(3):e0120640. https://doi.org/10.1371/journal.pone.0120640Article PubMed PubMed Central CAS Google Scholar 
31. Oberman LM, Edwards D, Eldaief MC, Pascual-Leone Á (2011) Safety of theta burst Transcranial Magnetic Stimulation: A Systematic Review of the literature. J Clin Neurophysiol 28(1):67–74. https://doi.org/10.1097/wnp.0b013e318205135fArticle PubMed PubMed Central Google Scholar 
32. George MS, Nahas Z, Borckardt JJ, Anderson B, Foust MJ, Burns C, Köse S, Short EB (2007) Brain stimulation for the treatment of psychiatric disorders. Curr Opin Psychiatry 20(3):250–254. https://doi.org/10.1097/yco.0b013e3280ad4698Article PubMed Google Scholar 
33. Wassermann EM, Lisanby SH (2001) Therapeutic application of repetitive transcranial magnetic stimulation: a review. Clin Neurophysiol 112(8):1367–1377. https://doi.org/10.1016/s1388-2457(01)00585-5Article PubMed CAS Google Scholar 
34. Zaghi S, Acar M, Hultgren BA, Boggio PS, Fregni F (2009) Noninvasive Brain Stimulation with Low-Intensity Electrical Currents: Putative Mechanisms of Action for Direct and Alternating Current Stimulation. Neuroscientist 16(3):285–307. https://doi.org/10.1177/1073858409336227Article PubMed Google Scholar 
35. Williams J, Imamura M, Fregni F (2009) Updates on the use of non-invasive brain stimulation in physical and rehabilitation medicine. J Rehabil Med 41(5):305–311. https://doi.org/10.2340/16501977-0356Article PubMed Google Scholar 
36. Cassani R, Novak GS, Falk TH, De Oliveira AA (2020) Virtual reality and non-invasive brain stimulation for rehabilitation applications: a systematic review. Journal of Neuroengineering and Rehabilitation 17(1). https://doi.org/10.1186/s12984-020-00780-5
37. Massetti T, Crocetta TB, Da Silva TD, Trevizan IL, Arab C, Caromano FA, De Mello Monteiro CB (2016) Application and outcomes of therapy combining transcranial direct current stimulation and virtual reality: a systematic review. Disabil Rehabil Assist Technol 12(6):551–559. https://doi.org/10.1080/17483107.2016.1230152Article PubMed Google Scholar 
38. Subramanian S, Prasanna SS (2018) Virtual reality and noninvasive brain stimulation in stroke: How effective is their combination for Upper limb motor Improvement?—A Meta-Analysis. PM&R 10(11):1261–1270. https://doi.org/10.1016/j.pmrj.2018.10.001Article Google Scholar 
39. Meng J, Yan Z, Gu F, Tao X, Xue T, Liŭ D, Wang Z (2023) Transcranial direct current stimulation with virtual reality versus virtual reality alone for upper extremity rehabilitation in stroke: A meta-analysis. Heliyon 9(1):e12695. https://doi.org/10.1016/j.heliyon.2022.e12695Article PubMed Google Scholar 
40. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann T, Mulrow CD, Shamseer L, Tetzlaff J, Akl EA, Brennan S, Chou R, Glanville J, Grimshaw J, Hróbjartsson A, Lalu MM, Li T, Loder E, Mayo‐Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch V, Whiting P, Moher D (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ :n71. https://doi.org/10.1136/bmj.n71
41. Liberati A, Altman DG, Tetzlaff J, Mulrow CD, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies that Evaluate Health Care Interventions: Explanation and Elaboration. PLoS Med 6(7):e1000100. https://doi.org/10.1371/journal.pmed.1000100Article PubMed PubMed Central Google Scholar 
42. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savović J, Schulz KF, Weeks L, Sterne JA (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343(oct18 2):d5928. https://doi.org/10.1136/bmj.d5928Article PubMed PubMed Central Google Scholar 
43. Jørgensen L, Paludan-Müller AS, Laursen DRT, Savović J, Boutron I, Sterne J a C, Higgins JPT, Hróbjartsson A (2016) Evaluation of the Cochrane tool for assessing risk of bias in randomized clinical trials: overview of published comments and analysis of user practice in Cochrane and non-Cochrane reviews. Systematic Reviews 5(1). https://doi.org/10.1186/s13643-016-0259-8
44. Yao X, Cui L, Wang J, Feng W, Bao Y, Xie Q (2020) Effects of transcranial direct current stimulation with virtual reality on upper limb function in patients with ischemic stroke: a randomized controlled trial. Journal of Neuroengineering and Rehabilitation 17(1). https://doi.org/10.1186/s12984-020-00699-x
45. Lee SJ, Chun MH (2014) Combination transcranial direct current stimulation and virtual reality therapy for upper extremity training in patients with subacute stroke. Arch Phys Med Rehabil 95(3):431–438. https://doi.org/10.1016/j.apmr.2013.10.027Article PubMed Google Scholar 
46. Lee S, Cha H-G (2021) The effect of clinical application of transcranial direct current stimulation combined with non-immersive virtual reality rehabilitation in stroke patients. Technol Health Care 30(1):117–127. https://doi.org/10.3233/thc-212991Article Google Scholar 
47. Llorens RC, Fuentes MA, Llorens RC, Latorre J, Alcañíz M, Colomer C, Noé E (2021) Effectiveness of a combined transcranial direct current stimulation and virtual reality-based intervention on upper limb function in chronic individuals post-stroke with persistent severe hemiparesis: a randomized controlled trial. Journal of Neuroengineering and Rehabilitation 18(1). https://doi.org/10.1186/s12984-021-00896-2
48. Viana R, Laurentino GEC, De Souza RMCR, Fonseca JB, Filho EM, Dias S, Teixeira-Salmela LF, Monte-Silva K (2014) Effects of the addition of transcranial direct current stimulation to virtual reality therapy after stroke: A pilot randomized controlled trial. NeuroRehabilitation 34(3):437–446. https://doi.org/10.3233/nre-141065Article PubMed CAS Google Scholar 
49. Cheng Z, Liao W, Xia W (2015) Effect of combined low-frequency repetitive transcranial magnetic stimulation and virtual reality training on upper limb function in subacute stroke: a double-blind randomized controlled trail. J Huazhong Univ Sci Technol 35(2):248–254. https://doi.org/10.1007/s11596-015-1419-0Article Google Scholar 
50. Chen Y, Chen C-L, Huang Y, Chen H-C, Chen C-Y, Wu C, Lin K (2021) Augmented efficacy of intermittent theta burst stimulation on the virtual reality-based cycling training for upper limb function in patients with stroke: a double-blinded, randomized controlled trial. Journal of Neuroengineering and Rehabilitation 18(1). https://doi.org/10.1186/s12984-021-00885-5
51. Oosterveer DM, Wermer MJH, Volker G, Vlieland TPMV (2022) Are there differences in Long-Term functioning and recovery between hemorrhagic and ischemic stroke patients receiving rehabilitation? J Stroke Cerebrovasc Dis 31(3):106294. https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106294Article PubMed Google Scholar 
52. Perna R, Temple J (2015) Rehabilitation Outcomes: Ischemic versus Hemorrhagic Strokes. Behav Neurol 2015:1–6. https://doi.org/10.1155/2015/891651Article Google Scholar 
53. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC,…Zorowitz RD (2016) Guidelines for Adult Stroke Rehabilitation and Recovery. Stroke, 47(6). https://doi.org/10.1161/str.0000000000000098
54. Bernhardt J, Godecke E, Johnson L, Langhorne P (2017) Early rehabilitation after stroke. Curr Opin Neurol 30(1):48–54. https://doi.org/10.1097/wco.0000000000000404Article PubMed Google Scholar 
55. Kwakkel G, Kollen BJ, Van Der Grond JV, Prevo AJH (2003) Probability of regaining dexterity in the flaccid upper limb. Stroke 34(9):2181–2186. https://doi.org/10.1161/01.str.0000087172.16305.cdArticle PubMed Google Scholar 
56. Nishimura Y, Onoe H, Morichika Y, Perfiliev S, Tsukada H, Isa T (2007) Time-Dependent central compensatory mechanisms of finger dexterity after spinal cord injury. Science 318(5853):1150–1155. https://doi.org/10.1126/science.1147243Article PubMed CAS Google Scholar 
57. Dhamoon MS, Moon Y, Paik MC, Boden-Albala B, Rundek T, Sacco RL, Elkind MSV (2009) Long-Term functional recovery after first ischemic stroke. Stroke 40(8):2805–2811. https://doi.org/10.1161/strokeaha.109.549576Article PubMed PubMed Central Google Scholar 
58. Kolmos M, Christoffersen LC, Kruuse C (2021) Recurrent Ischemic Stroke – A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 30(8):105935. https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105935Article PubMed Google Scholar 
59. D’Souza CE, Greenway MRF, Graff-Radford J, Meschia JF (2021) Cognitive Impairment in Patients with Stroke. Semin Neurol 41(01):075–084. https://doi.org/10.1055/s-0040-1722217Article Google Scholar 
60. De Luca R, Russo M, Naro A, Tomasello P, Leonardi S, Santamaria F, Desireè L, Bramanti A, Silvestri G, Bramanti P, Calabrò RS (2018) Effects of virtual reality-based training with BTs-Nirvana on functional recovery in stroke patients: preliminary considerations. Int J Neurosci 128(9):791–796. https://doi.org/10.1080/00207454.2017.1403915Article PubMed Google Scholar 
61. Zhang Q, Fu Y, Lu Y, Zhang Y, Huang Q, Yang Y, Zhang K, Li M (2021) Impact of Virtual Reality-Based Therapies on Cognition and Mental Health of Stroke Patients: Systematic Review and Meta-analysis. J Med Internet Res 23(11):e31007. https://doi.org/10.2196/31007Article PubMed PubMed Central Google Scholar 
62. Wu J, Zeng A, Chen Z, Wei Y, Huang K, Chen J, Ren Z (2021) Effects of Virtual Reality Training on Upper Limb Function and Balance in Stroke Patients: Systematic Review and Meta-Meta-Analysis. J Med Internet Res 23(10):e31051. https://doi.org/10.2196/31051Article PubMed PubMed Central Google Scholar 
63. Tedla JS, Sangadala DR, Reddy RS, Gular K, Kakaraparthi VN, Asiri F (2023) Transcranial direct current stimulation (tDCS) effects on upper limb motor function in stroke: an overview review of the systematic reviews. Brain Inj 37(2):122–133. https://doi.org/10.1080/02699052.2022.2163289Article PubMed Google Scholar 
64. Alashram AR, Padua E, Romagnoli C, Annino G (2019) Effectiveness of focal muscle vibration on hemiplegic upper extremity spasticity in individuals with stroke: A systematic review. NeuroRehabilitation 45(4):471–481. https://doi.org/10.3233/nre-192863Article PubMed Google Scholar 
65. Annino G, Alashram AR, Alghwiri AA, Romagnoli C, Messina G, Tancredi V, Padua E, Mercuri NB (2019) Effect of segmental muscle vibration on upper extremity functional ability poststroke. Medicine 98(7):e14444. https://doi.org/10.1097/md.0000000000014444Article PubMed PubMed Central Google Scholar 
66. Alashram AR, Annino G, Al-Qtaishat M, Padua E (2020) Mental practice combined with physical practice to enhance upper extremity functional ability poststroke: A Systematic review. J Stroke Med 3(2):51–61. https://doi.org/10.1177/2516608520943793Article Google Scholar 
67. Alashram AR, Annino G, Mercuri NB (2019) Task-oriented motor learning in upper extremity rehabilitation post stroke. J Stroke Med 2(2):95–104. https://doi.org/10.1177/2516608519864760Article Google Scholar 
68. Martin S, Cordeiro L, Richardson P, Davis S, Tartaglia N (2018) The association of motor skills and adaptive functioning in XXY/Klinefelter and XXYY syndromes. Phys Occup Ther Pediatr 39(4):446–459. https://doi.org/10.1080/01942638.2018.1541040Article PubMed PubMed Central Google Scholar 
69. Johnson D, Harris JE, Stratford PW, Richardson J (2018) Interrater reliability of three versions of the Chedoke arm and hand activity inventory. Physiother Can 70(2):133–140. https://doi.org/10.3138/ptc.2016-70Article PubMed PubMed Central Google Scholar 
70. Uswatte G, Taub E, Morris D, Vignolo MJ, McCulloch K (2005) Reliability and validity of the Upper-Extremity Motor Activity Log-14 for measuring Real-World arm use. Stroke 36(11):2493–2496. https://doi.org/10.1161/01.str.0000185928.90848.2eArticle PubMed Google Scholar 
71. Egger M, Smith GD (1998) meta-analysis bias in location and selection of studies. BMJ 316(7124):61–66. https://doi.org/10.1136/bmj.316.7124.61Article PubMed PubMed Central CAS Google Scholar 
72. Higgins JPT, Green S (2008) Cochrane Handbook for Systematic Reviews of Interventions. In: Wiley eBooks

Download references

Source

[ARTICLE] Effects of a virtual reality-based mirror therapy system on upper extremity rehabilitation after stroke: a systematic review and meta-analysis of randomized controlled trials – Full Text

Introduction: Virtual reality-based mirror therapy (VRMT) has recently attracted attention as a novel and promising approach for treating upper extremity dysfunction in patients with stroke. However, the clinical efficacy of VRMT has not been investigated.

Methods: This study aimed to conduct a meta-analysis to evaluate the effects of VRMT on upper extremity dysfunction in patients with stroke. We screened articles published between January 2010 and July 2022 in PubMed, Scopus, MEDLINE, and Cochrane Central Register of Controlled Trials. Our inclusion criteria focused on randomized controlled trials (RCTs) comparing VRMT groups with control groups (e.g., conventional mirror therapy, occupational therapy, physical therapy, or sham therapy). The outcome measures included the Fugl–Meyer assessment upper extremity test (FMA-UE), the box and block test (BBT), and the manual function test (MFT). Risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool 2.0. We calculated the standardized mean differences (SMD) and 95% confidence intervals (95% CI). The experimental protocol was registered in the PROSPERO database (CRD42022345756).

Results: This study included five RCTs with 148 stroke patients. The meta-analysis showed statistical differences in the results of FMA-UE [SMD = 0.81, 95% CI (0.52, 1.10), p < 0.001], BBT [SMD = 0.48, 95% CI (0.16, 0.80), p = 0.003], and MFT [SMD = 0.72, 95% CI (0.05, 1.40), p = 0.04] between the VRMT and the control groups.

Discussion: VRMT may play a beneficial role in improving upper extremity dysfunction after stroke, especially when combined with conventional rehabilitation. However, there were differences in the type of VRMT, stage of disease, and severity of upper extremity dysfunction. Multiple reports of high-quality RCTs are needed to clarify the effects of VRMT.

Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022345756.

1 Introduction

Mirror therapy (MT) is a treatment modality that induces cortical reorganization and promotes plastic changes in the brain without requiring movement of the affected limb (1). MT was initially reported by Ramachandran et al. (2), as a promising intervention for reducing phantom pain in amputees. Since then, it has been used as a therapeutic approach to address upper extremity dysfunction in patients with stroke (3). In a systematic review and meta-analysis conducted by Thieme et al. (4), MT was shown to be effective in improving upper extremity motor function, motor disability, activities of daily living, and pain and is considered to be a complementary treatment to conventional therapy for stroke patients, aiding in their recovery.

The development of innovative technologies has led to a considerable focus on new stroke rehabilitation approaches that utilize virtual reality (VR). VR systems can be categorized into three types: non-immersive, semi-immersive, and immersive (5, 6). Recently, a growing number of intervention studies have used immersive VR with head-mounted displays (HMDs) in patients with stroke (6). These VR systems have been suggested to induce neural plasticity and contribute to functional recovery after stroke (7, 8). Additionally, the VR-based mirror therapy system (VRMT), which applies the concept of MT, is expected to be an effective and innovative treatment method compared with conventional MT (cMT) (9, 10). Several previous studies have reported similarities in brain activity between VRMT and cMT (11–14). These findings indicate that VRMT induces neural plasticity, providing sufficient neurophysiological basis for its clinical application. However, the clinical effects of VRMT have not been investigated.

This review investigated the effects of VRMT on the upper extremities after stroke. We defined VRMT as “synchronized visual feedback of the affected side’s movement with that of the unaffected side.” […]

Continue

[WEB] The Use of Virtual Reality in Physical Therapy

By Medriva

THE FUTURE IS HERE: LEVERAGING VIRTUAL REALITY IN PHYSICAL THERAPY

As we stride into the 21st century, the fusion of health and technology has brought about a major revolution in the medical field. One such innovation is the use of Virtual Reality (VR) in physical therapy. This groundbreaking development is changing the game for therapists and patients alike, making therapy sessions more engaging, effective, and manageable. Let’s delve into the realm of VR and its transformative impact on physical therapy.

Understanding Virtual Reality

Virtual Reality, often abbreviated as VR, is a computer-generated simulation that allows users to interact in an artificial three-dimensional environment using electronic devices such as special goggles with a screen or gloves fitted with sensors. It provides the user with an immersive experience that can be similar to or entirely different from the real world.

The Emergence of VR in Physical Therapy

Physical therapy has traditionally been a field that relies heavily on physical interaction, manipulation, and exercises. However, technology has started to seep into this field, with Virtual Reality leading the charge. VR in physical therapy, sometimes referred to as “VR Physiotherapy,” is an innovative approach to treatment that leverages the immersive qualities of VR to aid in patient rehabilitation.

How Does VR Physiotherapy Work?

In VR physiotherapy, patients wear VR headsets that transport them to a virtual environment. In this environment, they can perform a series of exercises or maneuvers guided by their therapist. The technology allows for the tracking of movements and measurement of progress, providing valuable data for both the patient and the healthcare provider.

The Benefits of Using VR in Physical Therapy

VR in physical therapy is not just a fancy tech upgrade; it brings several substantial benefits to the table.

• Increased Engagement: VR can make physical therapy sessions more engaging and enjoyable for patients. Instead of monotonous exercises, they get to interact with a stimulating virtual environment.
• Better Compliance: The fun and interactive nature of VR physiotherapy can lead to better compliance with therapy regimes, which is often a major challenge in physical therapy.
• Improved Physical Performance: VR physiotherapy can lead to improved balance, muscle strength, and overall physical performance, as found in several research studies.
• Enhanced Feedback: VR systems can provide real-time feedback, helping patients understand their progress and areas of improvement.
• Reduced Perception of Pain: The immersive nature of VR can act as a distraction, reducing the perception of pain during strenuous exercises.

The Future of VR in Physical Therapy

While the use of VR in physical therapy is still in its early stages, the future looks promising. As technology advances, we can expect to see more sophisticated VR systems that provide personalized therapy experiences, better motion tracking, and even remote therapy options. Furthermore, with the cost of VR technology decreasing, it will become a more accessible tool for a larger number of clinics and patients.

Conclusion

The use of Virtual Reality in physical therapy is an exciting development that is transforming the field. It is enhances patient engagement, improves therapy outcomes, and offers a novel approach to rehabilitation. As we continue to explore and develop this technology, the realm of physical therapy is set to become even more dynamic and patient-friendly.

Source

[Abstract] Application of Virtual Reality Technology in Post-Stroke Depression

Abstract 

---

Post-stroke depression (PSD) is one of the most common complications of emotional disorders after stroke, and the recovery effect of clinical intervention using conventional means is limited. As an emerging technology, virtual reality technology provides a new idea for the clinical rehabilitation of patients with post-stroke depression. Through literature retrieval and review of domestic and foreign studies, this paper summarizes the development of virtual reality technology in psychotherapy. This paper expounds the application value of virtual reality technology in post-stroke depression, summarizes the common types of virtual reality technology combined with conventional intervention to treat post-stroke depression, and analyzes the influence of virtual reality technology on physical and mental rehabilitation of patients with post-stroke depression combined with empirical data. At the same time, the positive significance of virtual reality technology popularization and application is discussed. Finally, it is concluded that virtual reality technology can make up for the shortcomings of traditional treatment in the application of post-stroke depression, and can effectively improve the physical and mental state of patients. The application prospect is broad, but there is still room for development and improvement.

Full text links 

---

Read article for free, from open access legal sources, via Unpaywall: https://ebooks.iospress.nl/pdf/doi/10.3233/SHTI230866

Read article at publisher’s site: https://doi.org/10.3233/shti230866

[WEB] Research to Evaluate Remote Rehab for Stroke Survivors

New research, led by experts at the University of Nottingham, will look at how people affected by stroke will benefit from telerehabilitation.

Telerehabilitation is the remote provision of rehabilitation services including assessment, therapy and education using a range of technologies such as telephone and video conferencing, digital applications and virtual reality programmes.

It complements face-to-face care and could help community stroke services provide more therapy to more people, regardless of where they live. Although telerehabilitation is increasingly being used in practice, there is a lack of recommendations to inform whether and how it should be offered to different groups of stroke survivors.

The new study is led by Dr Niki Chouliara from the School of Medicine at the University of Nottingham and is called TELSTAR (TELerehabilitation in STroke CARe). The work is funded by the Stroke Association and aims to clarify whether, how and for who stroke telerehabilitation may be beneficial in community settings. The team will work with rehabilitation professionals, stroke survivors and family carers, Integrated Stroke Delivery Networks and NHS England to develop recommendations for practice that consider clinicians’ and stroke survivors’ needs and priorities.

 “We will look at the evidence and work with clinicians and people affected by stroke to understand who may benefit from telerehabilitation and who it should not be the preferred mode of delivery. We need recommendations to ensure telerehabilitation is delivered in line with existing evidence and that the needs and preferences of people with stroke are considered and respected.”

Researchers will reach out to groups of people who may have been left out by previous research on this topic, including those from diverse ethnic and socioeconomic backgrounds. Findings may help identify groups of people who may be disadvantaged in relation to accessing and benefiting from telerehabilitation and alert researchers, clinicians, and service providers.

Professor Adam Gordon, NIHR Senior Investigator, President of the British Geriatrics Society, and Professor of the Care of Older People in the School of Medicine at the University, said: “This is an exciting study and an important step towards developing recommendations to support the provision of high quality and equitable community stroke rehabilitation services. We often see telerehabilitation and other technological fixes touted as possible solutions to the current workforce crises in health and social care, and the pressures we see on the system as a consequence. It’s important, though, that we only use these technologies where the can make a difference to improve the quality of care.”

The research will also involve a team of experts in stroke rehabilitation from England and Scotland, including Professor Lisa Kidd, from Glasgow Caledonian University’s School of Health and Life Sciences, who said: “Greater use of telerehabilitation has been accelerated by the pandemic and may provide a way of addressing many of the challenges community rehabilitation teams face in providing consistent and high-quality rehabilitation that aligns with people’s priorities. The work that Dr Chouliara and Professor Gordon are leading on will greatly enhance our understanding of how telerehabilitation interventions work, for whom they work best and under what circumstances, so that long-term care, rehabilitation and support can be more meaningfully tailored to people’s needs.”

https://64ae8b6bd1a36677305b7cc7e716205b.safeframe.googlesyndication.com/safeframe/1-0-40/html/container.html

A key output from this work will be the development of a network of people with a specialist interest in stroke telerehabilitation and rehabilitation technologies, who will work together to promote research advances and inform improvements in clinical practice.

Sarah Adderley, Associate Director for the Midlands at the Stroke Association said: “We are delighted to be funding this research, which will provide insights into the effectiveness of telerehabilitation for stroke recovery. We are pleased that this grant will help Dr Chouliara work with communities that are typically underrepresented in research, so that support for stroke survivors can be improved.

“Stroke rehabilitation is vital. In addition to funding research, our charity supports thousands of stroke survivors through one of the most frightening times of their lives. In addition to our helpline, people may also receive much needed, personalised support via our Stroke Association Support Coordinators as they navigate their way through their life after stroke.

“Our support is informed by studies like Dr Chouliara’s. This project will give us valuable insight that will help us to support more people to rebuild their lives in better ways, improving stroke recoveries across the UK.”

The Stroke Association is the UK’s leading stroke charity and research is a vital part of their work. They have funded over £55 million of stroke research since the early 1990s, and currently fund £2.5 million of stroke research every year. This research has covered all areas related to stroke care and support, from prevention and emergency care to rehabilitation and long-term support. The Stroke Association Research Strategy can be found here: https://www.stroke.org.uk/research/our-plans-for-stroke-research

/Public Release. This material from the originating organization/author(s) might be of the point-in-time nature, and edited for clarity, style and length. Mirage.News does not take institutional positions or sides, and all views, positions, and conclusions expressed herein are solely those of the author(s).View in full here.

Source

[ARTICLE] Perspectives of Motor Functional Upper Extremity Recovery with the Use of Immersive Virtual Reality in Stroke Patients – Full Text

Abstract

Stroke is one of the leading causes of disability, including loss of hand manipulative skills. It constitutes a major limitation in independence and the ability to perform everyday tasks. Among the numerous accessible physiotherapeutic methods, it is becoming more common to apply Virtual Reality “VR”. The aim of this study was to establish whether immersive VR was worth considering as a form of physical therapy and the advisability of applying it in restoring post-stroke hand function impairment. A proprietary application Virtual Mirror Hand 1.0 was used in the research and its effectiveness in therapy was compared to classical mirror therapy. A total of 20 survivors after ischaemic stroke with comparable functional status were divided into a study group (n = 10) and control group (n = 10). Diagnostic tools included 36-Item Short Form Survey “SF-36” and the Fugl-Meyer Assessment Upper Extremity “FMA-UE”. Collected metrics showed a normal distribution and the differences in mean values were tested by the student’s t-test. In both, the study and control groups’ changes were recorded. A statistically significant outcome for FMA-UE and SF-36 measured by the student’s t-test for dependent or independent samples (p > 0.05) were obtained in both groups. Importantly, proven by conducted studies, an advantage of VR proprietary application was subjective sensations amelioration in pain and sensory impressions. Applying Virtual Mirror Hand 1.0 treatment to patients after a stroke appears to be a good solution and definitely provides the opportunity to consider VR applications as an integral part of the neurorehabilitation process. These results give a basis to plan further larger-scale observation attempts. Moreover, the development of the Virtual Mirror Hand 1.0 as an innovative application in physiotherapy may become equivalent to classical mirror therapy in improving the quality and effectiveness of the treatment used for post-stroke patients.

Keywords: 

stroke; virtual reality; upper limb; motor function; mirror therapy

1. Introduction

Nowadays, it is inevitable to apply digital solutions in clinical health care. The intensification of this process is provided by the worldwide tendency to develop technological solutions. This transfers into the possibility of gathering data, validating the performance of a patient’s tasks and accurate reflexion of the demanded movement. Based on the clinical experience, the continuation of the rehabilitation process is often practiced at home, which could be successfully resolved by Virtual Reality “VR” appliances and the possibility to remotely monitor the patient’s condition [1,2,3,4]. A significant part of numerous functional stroke symptomatology is manipulative skills dysfunction [5]. This impairment appears as a stroke consequence in almost 60% of cases and can last for more than 12 months [6]. Many years of clinical observations allow for the establishment of a thesis that the restoration of manipulative function is a complex and demanding task [7]. Therefore, various descriptions dedicated to this issue can be found in the literature which provide methods that specify their effectiveness. In the last decade, the use of a botulinum toxin followed by exercises [8], vibration training [9,10], kinesiotaping [11], electrostimulation [12], use of dynamic splint [13] and constraint-induced movement therapy were postulated in rehabilitation [14,15]. The results of research dedicated to mirror therapy being used in order to deal with manipulative skills impairments appear promising [16,17,18,19]. Recently, due to computer technology development, successful use of VR in improving fine motor skills in stroke patients is observed [20,21,22,23]. The mentioned scientific reports are describing the effects of a particular method in relation to the control group, in which it is excluded from the rehabilitation program. However, we have not found any research that would compare the above-mentioned methods giving evidence of the advantage of one over the other in the literature. We assumed that in order to improve the manipulative hand functions, it is beneficial to combine a traditional approach with innovative computer technology, known as virtual rehabilitation or VR [24]. The treatment basis of classic mirror and VR application therapies focuses on the same principle: the patient sees his impaired hand moving and an exact imitation of the not-plegic side motion is presented either in the mirror reflection or in the head-mounted display. VR is an image of “artificial reality” created by multiple devices interconnected by a computer system. Therefore, as a classic approach was already a theme of multiple research projects, we decided to compare the effects of mirror therapy and VR application. A VR system uses the role of visual feedback to make stimuli reaching the patients as realistic as possible. Mei-Hong Zhu et al. devoted their attention to this issue [25]. In the traditional approach to the subject, VR application in the rehabilitation field not only needs dedicated computer software, but also devices that display and collect information about the patients’ movement. The display equipment includes traditional computer monitors, LCD screens and projectors [26]. The most modern systems, Cave Automatic Virtual Environment “CAVE”, represent a high-tech solution, in which projectors present a stereoscopic image on the walls and floor of the room. Patients using this system need to wear stereoscopic glasses to be able to view 3D images [27]. With a second kind of display device being glasses or Head-Mounted Display “HMD”. In order to conduct therapy more effectively, equipment that detects a patient’s movement and provides biofeedback in the form of an image is required. This is possible due to a motion detector or 3D cameras giving the patient the possibility to react and to fulfil a task appearing on the screen or a console [28]. Depending on the display equipment used, there exist VR types: VR with immersion (immersive VR), augmented VR and Mixed Reality “MR”.

In the first one, the activation of proprioceptive sensations let the patient feel that he is being transferred to another multisensory environment, that helps patient keep his attention on a given task. This effect can be obtained due to a HMD-type display placed in a helmet or glasses that isolate the person from their surroundings. When a sound or an avatar character that reflects the patient’s movement is added, an even greater immersion effect can be achieved [29]. We decided to choose that VR type according to the above-mentioned reasons.

In the second type of VR, augmented VR, the user sees both the natural environment and virtual characters or objects placed. This technology integrates application content into real-world settings [30].

In the third type of environment, MR, the latest sensory solutions and imaging technologies are used. The patients register both images displayed by LCD screens or projectors and other objects and people present in the room; thus, receiving stimuli from the virtual world and natural environment [4].

As a conclusion, most beneficial solution for the post-stroke patient might be immersive VR. That VR type provides isolation from the real environment as an essential feature in focusing attention and the correct interpretation of the movement. What is more for the patient, there are no distractive factors, but only a pure image regardless of external stimuli. Adherence to neurotherapy and optimising therapeutic aims can be effectively achieved [4]. Due to dedicated software, the therapy scheme as well as recorded results are saved in the memory of VR device. This allows for the observation of the progress of treatment, to capture weak the point of therapy and to plan the next stages of rehabilitation. VR application use is a modern technology solution simplifying the therapeutic process and collecting a great database in order to conduct diagnostics and to be used in further research [29].

The aim of this study was to establish whether immersive VR was worth considering as a form of physical therapy and the advisability of applying it in restoring post-stroke hand function impairment. Our clinical concept is derived from widely known in the neurorehabilitation mirror therapy.

2. Materials and Methods

2.1. Participants

Randomized studies on 20 patients of Neurological Rehabilitation Department “STROKE” in Wiktor Dega Orthopaedic and Rehabilitation Clinical Hospital in Poznan were conducted from July 2022 to October 2022. The following inclusion criteria were defined and enforced during the qualification assessment:-

diagnosis of first-episode stroke,-

age range 40–64,-

acquired motor impairment of hemiplegic upper limb,-

maximum of 12 months period since diagnosis,-

functional brain damage specified with Rankin scale 1–4 at the last hospital discharge.

Certain exclusion criteria were admitted:-

requirement of constant, intensive medical surveillance,-

active comorbidities significantly influencing rehabilitation process (ex. bone fractures occurred during medical treatment, pressure ulcers, etc.),-

circulatory insufficiency, kidney, liver failure, condition after myocardial infarction with ejection fraction less than 30%,-

vascular disease (active thromboembolism),-

heart aneurysm, aortic aneurysm, malformation of cerebral vessels,-

active inflammation,-

uncompensated endocrine disruption,-

cancer (palliative care or need of urgent treatment),-

severe arterial or pulmonary hypertension,-

uncontrolled diabetes,-

epilepsy.

The above-mentioned criteria were made in order not to disturb or to be a risk during the neurorehabilitation process.

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Poznan University of Medical Sciences (protocol code 587/22, date of approval 23 June 2022). Informed written consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper.

In this research, we selected patients from the “STROKE” Department and then randomly divided into two, equal in terms of number study and control group.

Twenty patients with hemiplegia dexter according to computer tomography scan and 3.1 ± 0.57 points in the study (min-max, 2–4) and 3.3 ± 0.67 points in the control group in Rankin Scale (min-max, 2–4) were included in the trial. Mean time after right-sided stroke diagnose (and occurrence) caused by right medial cerebral artery ischaemia resulting in plegic left upper limb was 3.4 ± 1.43 months in the study and 3.3 ± 0.67 points in the control group. All participants of this study were after the first stroke and took part in the first rehabilitation program. The mean age of patients in the experimental group was 54.9 ± 3.98 years, in the control group it was 59.2 ± 4.34 years, and in both groups, it was 57.05 ± 4.62 years. Duration of the research for each group, consistent with the “STROKE” project establishments, was 18 days and occurred in three consecutive weeks, form Monday to Saturday. Each participant of the research was assessed with quality-of-life scale 36-Item Short Form Survey “SF-36” and related to sensorimotor function of upper limb Fugl-Meyer Assessment Upper Extremity “FMA-UE” before the therapy starts.

2.2. VR Application

Patients in the study group followed a physical therapy treatment of upper limb with the use of SciMed system which includes the immersive VR application Virtual Mirror Hand 1.0, implemented on the Oculus Quest 2 VR glasses module (Figure 1).

Figure 1. Oculus Quest 2 module.

[…]

Continue

[ARTICLE] Virtual Reality Music Instrument Playing Game for Upper Limb Rehabilitation Training – Full Text

The motor function of the upper limb is typically impaired in stroke patients; as a result, rehabilitation exercise is crucial to regaining muscular control. While encouraging patients to continue with long-term exercise using standard rehabilitation training methods may be difficult. To deal with this dilemma, virtual reality (VR) games are introduced to motivate patients to take part in therapy. Meanwhile, music therapy has been proven to be extremely beneficial in the early phases of stroke recovery. These activities inspire us to include musical instrument play like xylophone and drums, in the design of VR games. By striking the xylophone’s highlighted keys or the flying notes aimed at the drums, the impaired upper limb functions can be strengthened. Early user evaluations demonstrate that the developed games are straightforward to use and appeal to patients’ desire for more exercise.

1 INTRODUCTION

Tangible games are widely utilized to motivate patients and track their performance to support therapists better [9, 10, 11], while some recent research studies also adopt virtual reality (VR) games in redesigning upper limb exercises. VR games and actual movements can be integrated together to motivate patients in rehabilitation exercises. Rose et al. [7] reported that patient enjoyment and willingness to participate were concluded in healthcare plans incorporating VR due to its immersive, entertaining approach to improving performance. However, some VR games may provide repetitive, intense, and task-specific training to enhance neuroplasticity [8]. In order to mitigate this issue, music therapy, which has been demonstrated to aid in both physical and mental rehabilitation, has been proven to be extremely beneficial in the early phases of stroke recovery [4]. Both sorts of engagement can benefit stroke patients, but generally speaking, low-cost methods have more real-world use. The price of VR-based headset has been extremely expensive in the past. With the improvement of technology, a few cost-effective VR devices are launched in the market, such as PICO4 (an all-in-one device around $425 as shown in Fig. 1), which creates more opportunities for VR game development. In this study, we focus on rhythm-based upper-limb training exercises by incorporating musical instrument playing into VR game design. As a result, the two musical instruments, i.e., the xylophone and drums, are applied to the game design with tactile, auditory, and visual feedback.

2 RELATED WORKS

Projects like TangiBoard demonstrated how sensory technology and tangibles can generally enrich learning and training experience in upper limb rehabilitation [5, 6]. In recent years, many projects aimed to tackle similar problems using VR technology by picking up and positioning objects in the virtual environment at specific places [6]. For example, the Bimeo gadget provided a VR environment to encourage patients to rehabilitation exercise, as well as support therapists to oversee and manage the exercise [1]. The ArmeoSenso system [5] similarly used VR and inertial measurement unit (IMU) for video game-based training and assessment of upper limb functions. VR games have been explored as tools in rehabilitation training.

Playing therapeutic instrumental music assists patients in regaining functional movement patterns and damaged motor functions [3]. Connie Tomaino, the director of the Beth Abraham Music and Neurologic Rehabilitation Institute, states that “focusing attention on rhythmic instruments can increase movement in individuals such as those with Parkinson’s disease or stroke rehabilitation patients” [2]. In music therapy, drums and xylophone are very popular instruments since people without prior knowledge can quickly learn how to play. In fact, stroke rehabilitation patients may exercise more if they concentrate on rhythmic instruments [2]. As a result, we decided to build a rhythm-based VR game using drums and xylophone play for rehabilitation exercise.

3 CONCEPTUAL DESIGN AND GAME PROTOTYPING

We observed patients performing arm-reaching exercises while conducting field research at a local rehabilitation facility, Suzhou Municipal Hospital, by moving a wooden instrument on the table. This exercise is vital to inhibit muscular contraction in the initial stages of stroke recovery. Patients moved from one posture to another as directed by therapists verbally. Even under the care of therapists, patients were quite inactive, although they could exercise independently. To sum up, we identify the design opportunity as providing a low-cost training device that motivates and guides patients through active exercising tasks. Meanwhile, therapists should be able to monitor multiple patients simultaneously and record their performances.

As a result, we created a VR game concept utilizing PICO4 to encourage them to complete the practice. The stroke patients held two controllers that weighed 185 grams each while wearing headsets. Through gripping the controllers, users can play virtual music instruments for upper limb reaching, stretching and extension. PICO4 device can mirror the VR display from the headsets to other devices such as televisions, computers, and smartphones. With this screen mirroring capability, clinicians could not only provide guidance and assistance to patients, but also monitor their gaming performance in real-time. Two distinct game modes are primarily designed: ‘Xylophone Play Mode’ and ‘Drums Play Mode’ to support appropriate upper limb functional training. Two iterations of VR game design are explored to facilitate arm reaching, shoulder extension, wrist and elbow rotation exercises.

Figure 1: PICO 4 Device

3.1 First Edition

In the ‘Xylophone Play Mode’, patients move virtual mallets by arm movement to strike the keys. A melody can be generated by pointing, rotating the wrist, and moving the mallet up and down to strike the keys. This game can improve upper limb-eye coordination and fine motor control.

In the ‘Drums Play Mode’, the rhythmical notes fly and move directly towards the corresponding drums with the background music. Patients use the virtual drumsticks to catch those notes above the drums, and successful strikes are rewarded with points. Clinicians can gauge the patients’ progress based on the scores received and decide whether they can move on to more challenging levels. For user-intuitive feedback, a successful note-catching would trigger a drum beat sound with controller vibration and an explosion effect. We tested our VR game in Suzhou Municipal Hospital Rehabilitation Center and received the following therapist response. Task-driven functionality, such as highlighting particular keys on xylophone to guide users exercise, should be included in the ‘Xylophone Play Mode’. The flight speed of such rhythmical notes in the ‘Drums Play Mode’ is too quick, which causes much miss catching in the exercise. As a result, two difficulty levels are designed for this mode in the revised version: basic level and standard level.

Continue