Posts Tagged virtual reality
Background: Stroke is the leading cause of serious long-term disability in the United States. Barriers to rehabilitation include cost, transportation, lack of trained personnel, and equipment. Telerehabilitation (TR) has emerged as a promising modality to reduce costs, improve accessibility, and retain patient independence. TR allows providers to remotely administer therapy, potentially increasing access to underserved regions.
Objectives: To describe types of stroke rehabilitation therapy delivered through TR and to evaluate whether TR is as effective as traditional in-person outpatient therapy in improving satisfaction and poststroke residual deficits such as motor function, speech, and disability.
Methods: A literature search of the term “telerehabilitation and stroke” was conducted across three databases. Full-text articles with results pertaining to TR interventions were reviewed. Articles were scored for methodological quality using the PEDro scale.
Results: Thirty-four articles with 1,025 patients were included. Types of TR included speech therapy, virtual reality (VR), robotic, community-based, goal setting, and motor training exercises. Frequently measured outcomes included motor function, speech, disability, and satisfaction. All 34 studies reported improvement from baseline after TR therapy. PEDro scores ranged from 2 to 8 with a mean of 4.59 ± 1.94 (on a scale of 0-10). Studies with control interventions, randomized allocation, and blinded assessment had significantly higher PEDro scores. All 15 studies that compared TR with traditional therapy showed equivalent or better functional outcomes. Home-based robotic therapy and VR were less costly than in-person therapy. Patient satisfaction with TR and in-person clinical therapy was similar.
Conclusions: TR is less costly and equally as effective as clinic-based rehabilitation at improving functional outcomes in stroke patients. TR produces similar patient satisfaction. TR can be combined with other therapies, including VR, speech, and robotic assistance, or used as an adjuvant to direct in-person care.
- Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial.Cramer SC, Dodakian L, Le V, See J, Augsburger R, McKenzie A, Zhou RJ, Chiu NL, Heckhausen J, Cassidy JM, Scacchi W, Smith MT, Barrett AM, Knutson J, Edwards D, Putrino D, Agrawal K, Ngo K, Roth EJ, Tirschwell DL, Woodbury ML, Zafonte R, Zhao W, Spilker J, Wolf SL, Broderick JP, Janis S; National Institutes of Health StrokeNet Telerehab Investigators.JAMA Neurol. 2019 Jun 24;76(9):1079-87. doi: 10.1001/jamaneurol.2019.1604. Online ahead of print.PMID: 31233135 Free PMC article.
- Maximizing post-stroke upper limb rehabilitation using a novel telerehabilitation interactive virtual reality system in the patient’s home: study protocol of a randomized clinical trial.Kairy D, Veras M, Archambault P, Hernandez A, Higgins J, Levin MF, Poissant L, Raz A, Kaizer F.Contemp Clin Trials. 2016 Mar;47:49-53. doi: 10.1016/j.cct.2015.12.006. Epub 2015 Dec 4.PMID: 26655433 Clinical Trial.
- Telerehabilitation services for stroke.Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C.Cochrane Database Syst Rev. 2013 Dec 16;2013(12):CD010255. doi: 10.1002/14651858.CD010255.pub2.PMID: 24338496 Free PMC article. Updated. Review.
- Study protocol: home-based telehealth stroke care: a randomized trial for veterans.Chumbler NR, Rose DK, Griffiths P, Quigley P, McGee-Hernandez N, Carlson KA, Vandenberg P, Morey MC, Sanford J, Hoenig H.Trials. 2010 Jun 30;11:74. doi: 10.1186/1745-6215-11-74.PMID: 20591171 Free PMC article. Clinical Trial.
- Scoping review of outcome measures used in telerehabilitation and virtual reality for post-stroke rehabilitation.Veras M, Kairy D, Rogante M, Giacomozzi C, Saraiva S.J Telemed Telecare. 2017 Jul;23(6):567-587. doi: 10.1177/1357633X16656235. Epub 2016 Jun 24.PMID: 27342850 Review.
You’ve probably heard a lot of recommendations on how to recover hand function after stroke. We sifted through the research for you to explain the top 5 medically proven methods for hand rehabilitation, why they work, and who they work for.
by CLARICE TORREY, 3 JUN 2020 • 8 MIN READ
After a stroke, it’s challenging enough to navigate the medical system to find what services you need, let alone the right treatment approach for you.
You’ve probably heard a lot of recommendations on how to recover hand function after stroke, and everyone seems to give different advice. That’s why we sifted through the research for you. We’ll explain the top 5 evidence-based methods for hand rehabilitation, why they work, and who they work for.
The top 5 evidence-based treatments for improving hand function after stroke:
- Constraint‐induced movement therapy (CIMT)
- Mental practice
- Mirror therapy
- Virtual reality
- High dose repetitive task practice
Constraint-Induced Movement Therapy
What it is:
Constraint-Induced Movement Therapy (CIMT) is a neuro-rehabilitation method where the non-affected hand is constrained or restricted in order to force the brain to use the affected hand, thereby increasing neuroplasticity.
There are two key components: constraint and shaping.
Constraint refers to the way in which the hand is restricted. Therapists have used casts, splints, and mitts to restrict the use of the non-affected hand. None of them have been shown to be more effective than the other.
Shaping involves repetitive movements or activities at the patient’s ability level which become progressively harder. Therapists use shaping techniques to avoid overwhelming the motor system.
Why it works:
Our brain automatically completes a task in the easiest way possible. Our brain is more interested in completing a task than in how it is accomplished.
After a stroke, it’s easier for our brain to do tasks one-handed. This leads to “learned non-use”.
When we constrain our non-affected hand, suddenly our stronger hand becomes the weaker, less functional hand and we’re forced to use our affected hand. Our affected hand might not have much movement, but to our brain any movement is better than no movement, and the brain is highly motivated to figure out how to accomplish a task.
This is where the “shaping” piece is so important. If you are presented with rehab tasks that overwhelm the motor system or are higher level than your affected hand can functionally do, you’ll be more likely to knock the table over than to participate in picking up pennies from the table.
If you knock the table over with your affected hand, your occupational therapist might actually be excited about it; but in practical life finding that balance of not being too easy and not being so hard that you give up is an important lesson for every human being, not just those after stroke.
Who it’s for:
This approach is used for people who have at least 10 degrees of active wrist and finger extension, as well as 10 degrees of thumb abduction (the ability of the thumb to move out of the palm).
It’s been shown to be effective even years after stroke. Lower intensity CIMT is better than higher intensity in the very early stages after stroke.
What it is:
Mental practice, sometimes called motor imagery or mental imagery, is a training method for improving your hand and arm function without moving a muscle!
Mental practice is typically done by listening to pre-recorded audio that describes in detail the motor movement of a specific task. The listener imagines their hand and arm moving in a “typical” way, and the instructor provides cues to extend their arm or open their fingers, as well as the entire sensory experience of the task.
While it’s true that you can do mental practice on its own, it’s best combined with physical practice immediately following.
Why it works:
Brain scans show that similar parts of the brain are activated whether movement is actual, observed or imagined.
It’s a separate area of the brain that’s responsible for actually triggering the muscle movement, but it goes to show that there’s a lot more required of the brain to complete a task than just sending a signal to the muscle.
Who it’s for:
Mental practice has been shown to improve arm movement and functional use in patients after stroke of all levels of abilities and as a treatment approach for people months or years after stroke!
What it is:
Mirror therapy is another voodoo-seeming approach that has a lot of scientific evidence to back it up. It essentially tricks your brain into thinking your affected hand is moving.
You position a mirror to reflect your non-affected hand, while hiding your affected hand. Any movement of your non-affected hand will be reflected in the mirror and make it seem as though you are actually moving your affected hand.
Why it works:
The approach is centered around mirror neurons, which fire in your brain when you see your arm move. Typically, we think about motor neurons being sent from the brain to the muscle, but we don’t realize that mirror neurons are connected to the motor neurons.
After a stroke you lose the ability to access your motor neurons, but not your mirror neurons. By accessing your mirror neurons through seeing your movement (even if the movement is fake), you are tapping into the network between the neurons.
It’s like trying to reconnect with an old friend on Facebook by finding the friends they’re connected with. It might not be the most direct approach in a real life situation, but in stroke rehab that friend of a friend might be your strongest connection.
Who it’s for:
Mirror therapy can be used for people with no movement of the hand or smaller movements of the hand and shoulder, but not functional movement of the hand.
If you have functional movement of your hand, meaning individual finger movement and wrist movement, you have surpassed the benefit that mirror therapy can provide.
It can be used early after stroke, as well as in the chronic stages of stroke.
What it is:
Virtual reality uses a computer interface to simulate a real life objects and events. It’s become an increasingly more prevalent rehabilitation technique to provide motivation and engagement in therapy.
There are two types:
- Immersive: goggles are placed over the eyes and the patient is visually in a different environment than their actual physical one
- Non-immersive: sensors are placed on the body and track the movement of the body and the movements are shown on a screen
Why it works:
Virtual reality works best when paired with traditional therapy. It’s theorized to provide more motivation and engagement for the intensity of therapeutic exercise needed for neuroplasticity. It’s been shown to beneficial in high doses, meaning more than 20 hours.
Another possible factor of why virtual reality works are the same mechanisms that make mirror therapy effective (tapping into the mirror neurons) could be similar.
Virtual reality also creates a biofeedback loop: your brain sends a signal to the muscle, the brain receives a signal back in the form of visual or auditory input. Basically, you get rewarded for your effort.
Who it’s for:
Virtual reality can be used with people who have mild to severe impairments, and from early after stroke to years out.
When deciding what’s right for you, it’s important to look at the adjustability of the device to meet you where you’re at and also to increase in difficulty as you improve.
If you have minimal movements, you’ll want a virtual reality tool specifically for stroke rehabilitation. If you have more movement, it’s possible to use gaming systems not specifically designed for rehab, but make sure you have the support to optimize it for rehab.
High Dose Repetitive Task Practice
What it is:
Repetitive Task Practice is when you practice a task or a part of a task over and over. Task-specific training is a type of repetitive task practice, and refers to the task we complete that is relevant to our daily life.
“Reach to grasp, transport and release” is a type of task-specific training because it is one of the common motor requirements for many functional daily tasks.
The keys for repetitive task practice:
- Task must be meaningful
- Participant must be an active problem-solver
- Real life objects are used
- Difficulty level is not too high and not too low
- Repetition is key
Why it works:
Repetitive Task Practice is based on motor learning theory. Our brains are driven by function. We’re able to achieve neuroplasticity with development of skills, as our brain processes the demands of the task, which have motor and cognitive components.
It’s often used with other treatments, such as virtual reality, to increase the 15 hour dosage that has been shown to be beneficial.
Who it’s for:
Task-specific practice is generally used and is studied in people who have some functional ability of their hand. It’s been shown to be beneficial throughout the rehabilitation process.
Even though the research has been focused on “functional ability” of the hand by practicing reach, grasp, transport, release; there’s potential for recovery by using the same principles of task-specific practice: real life objects, functional tasks, and problem-solving even without the ability to grasp.
Functionally, we can use our affected upper extremity as a stabilizer, an assist, or for manipulation. There are lots of ways to get that side involved to prevent “learned non-use” and to improve your problem-solving skills.
There are two key factors to any hand recovery method: support and meaning.
Neofect aims to support and inspire you to live your best life with virtual reality tools that can be used as part of a constraint-induced movement therapy program or with repetitive task practice.
Our comprehensive recovery and wellness app: Neofect Connect and our YouTube Channel: Find What Works are based on the principles of repetitive task practice and aim to give you the tools to live your best life.
Now the only question is, what are you waiting for?
Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F. Interventions for improving upper limb function after stroke. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010820. DOI: 10.1002/14651858.CD010820.pub2.
[Abstract] How brain imaging provides predictive biomarkers for therapeutic success in the context of virtual reality cognitive training
VR environments help improve rehabilitation of impaired complex cognitive functions
Combining neuroimaging and VR boosts ecological validity, generates practical gains
These are the first neurofunctional predictive biomarkers of VR cognitive training
As Virtual reality (VR) is increasingly used in neurological disorders such as stroke, traumatic brain injury, or attention deficit disorder, the question of how it impacts the brain’s neuronal activity and function becomes essential. VR can be combined with neuroimaging to offer invaluable insight into how the targeted brain areas respond to stimulation during neurorehabilitation training. That, in turn, could eventually serve as a predictive marker for therapeutic success. Functional magnetic resonance imaging (fMRI) identified neuronal activity related to blood flow to reveal with a high spatial resolution how activation patterns change, and restructuring occurs after VR training. Portable and quiet, electroencephalography (EEG) conveniently allows the clinician to track spontaneous electrical brain activity in high temporal resolution. Then, functional near-infrared spectroscopy (fNIRS) combines the spatial precision level of fMRIs with the portability and high temporal resolution of EEG to constitute an ideal measuring tool in virtual environments (VEs). This narrative review explores the role of VR and concurrent neuroimaging in cognitive rehabilitation.
[Abstract] Review on motor imagery based BCI systems for upper limb post-stroke neurorehabilitation: From designing to application
• BCI methods are among the most effective tool for designing rehabilitation systems
.• Use of virtual reality (VR) can increase the efficiency of BCI rehab systems
.• “FES,” “Robotics Assistance,” and “Hybrid VR based Models” are main BCI approaches.
• In the future, flexible electronics can be used for designing stroke rehab systems.
Strokes are a growing cause of mortality and many stroke survivors suffer from motor impairment as well as other types of disabilities in their daily life activities. To treat these sequelae, motor imagery (MI) based brain-computer interface (BCI) systems have shown potential to serve as an effective neurorehabilitation tool for post-stroke rehabilitation therapy. In this review, different MI-BCI based strategies, including “Functional Electric Stimulation, Robotics Assistance and Hybrid Virtual Reality based Models,” have been comprehensively reported for upper-limb neurorehabilitation. Each of these approaches have been presented to illustrate the in-depth advantages and challenges of the respective BCI systems. Additionally, the current state-of-the-art and main concerns regarding BCI based post-stroke neurorehabilitation devices have also been discussed. Finally, recommendations for future developments have been proposed while discussing the BCI neurorehabilitation systems.
A stroke is usually considered chronic at the six-month mark. This article reviews research on chronic stroke recovery and promising therapy treatment approaches that target improving limb function, even for an “old” stroke.
By Natalie Miller, Clinical Manager / Occupational Therapist. More posts by Natalie Miller.
27 MAR 2020 • 5 MIN READ
What is a chronic stroke?
The term chronic stroke typically refers to a time frame of at least six months after the initial stroke incident occurred. As a person enters this stage and moves onward to years of stroke survival, he may start to encounter all new frustrations related to recovery, especially regarding motor recovery and use of the affected arm.
In the medical world, “most significant” recovery of movement is generally considered to happen within the first six months, with spontaneous recovery slowing after that time. There is a push for high-intensity and high-frequency of therapy while the stroke is still fairly fresh, in order to capitalize on the “critical window” of the highest responsiveness to treatment.
That doesn’t mean we should stop addressing motor recovery after six months. What if we still focus on intensive therapy early on in stroke rehab, but also find ways to promote motor recovery six or more months later? What if we don’t stop searching for new strategies to improve, or at the very least, not lose function of the weaker arm?
Can I still improve function if I am in the chronic stage of stroke?
Our understanding of the brain and its capabilities is constantly evolving. We used to think that adult brains couldn’t change at all after a certain age! Emerging research evidence suggests there are ways to challenge and improve the chronic stroke brain months and even years down the road. One large-scale study involving outcomes from 219 stroke survivors suggested the critical window for motor recovery may be as long as 18 months! Another recent case study highlighted motor recovery in a stroke survivor who was 23 years post-stroke!
What types of rehabilitation are effective for people with chronic stroke?
Stroke research suggests the following treatments are promising for individuals who are at least six months post-stroke:
- Mental Practice with Motor Imagery
- Constraint Induced Movement Therapy (CIMT)
- Virtual Reality (VR)
- Preventing Learned Non-Use
Mental Practice with Motor Imagery
This is a type of treatment where a specific movement is rehearsed mentally. Done best with a pre-recorded audio set, the person listens carefully as a task is described in detail. The details usually include every aspect of that task, including how the five senses may be experienced while performing it, as well as the exact movements that would be needed to complete the task. For example, if the task were “drinking a cup of water,” the recording would describe how to reach out with the arm, extend the fingers, feel the weight of the cup, experience the temperature and the liquid as it touches the mouth, and the exactness of the motion to set it back down gently.
Studies have shown that with this type of repetitive visualization and practice, actual movement and functional use of the arm can improve, such that an arm that was once fairly “useless” can now actually pick up a water cup and bring it to the mouth. The best part is, research also shows that this can be an effective treatment 12 months and beyond since when the stroke actually happened!
Constraint Induced Movement Therapy (CIMT)
This is a type of treatment that involves blocking the stronger arm (usually with a cast or mitt) to promote engagement of the hemiplegic, or weaker arm. The more a person uses the weaker arm, the less they are at risk of “learned non-use.” By “forcing” the weaker arm to participate more, and even to be the primary or only source of function, it has a lot more chance to stay the same or get better, even years after the stroke happened. In fact, patients in Constraint Induced studies reported and showed increased use of their arms during normal activities, even if their strokes happened years before!
Virtual Reality (VR)
Virtual reality is another name for video games! This type of treatment may be immersive (using a headset) or non-immersive, with a participant engaging in a game on a screen. VR technology focusing on strengthening and improving limb function is becoming more prevalent in clinics and in homes. These programs are able to quantify arm or leg movement to control gameplay and provide immediate performance feedback.
Research supports the use of VR therapy to enhance motor recovery for adults with acute and chronic stroke. Virtual reality technology can also improve motivation in addition to movement outcomes, helping users stick with their self-training programs and continue using their affected side. Research shows that chronic stroke patients often find self-training programs that use video games to be user friendly and enjoyable.
Avoiding “learned non-use.”
We now know more about this phenomenon that affects many stroke survivors – especially those who are years out from a stroke. The stronger arm starts to take over to just get things accomplished, probably because there is a lot of positive feedback for using the stronger arm (It’s faster! It’s easier! I can just get it done!) and a lot of negative feedback for using the stroke-affected arm (It’s so frustrating! It takes me forever using it!). Research is showing that if people can still find motivation and dedication to actually trying to use the weaker arm, it is possible to still regain function – even years later.
The bottom line: don’t give up!
There IS hope. We can’t predict the exact amount of movement or strength that could come back, or what exactly you will be able to do with your affected arm or hand. But we are producing more research that is pointing us in the direction of believing recovery is still possible after that six month critical window. Don’t give up!
Ballester, BR, et al. (2019). A critical time window for recovery extends beyond one-year post-stroke. Journal of Neurophysiology, 122: 350-357. doi: 10.1152/jn.00762.2018
Soros, P, et al. (2017). Motor recovery beginning 23 years after ischemic stroke. Journal of Neurophysiology, 118(2): 778-781. doi: 10.1152/jn.00868.2016
Page, S, Levine, P, and Leonard, A. (2007). Mental practice in chronic stroke: results of a randomized, placebo-controlled trial. Stroke, 38(4): 1293-1297. doi: 10.1161/01.STR.0000260205.67348.2b
Kunkel, A, et al. (1999). Constraint-induced movement therapy for motor recovery in chronic stroke patients. Archives of Physical Medicine and Rehabilitation, 80, 624-628. doi:10.1016/s0003-9993(99)90163-6
5. Taub, E, et al. (1993). Technique to improve chronic motor deficit after stroke. Archives of Physical Medicine and Rehabilitation, 74, 347-354.
Subramanian, SK, et al. (2013). Arm motor recovery using a virtual reality intervention in chronic stroke: Randomized control trial. Neurorehabilitation and Neural Repair, 27(1), 13-23. doi: 10.1177/1545968312449695.
[Abstract] Exercise intensity of the upper limb can be enhanced using a virtual rehabilitation system.
Purpose: Motor recovery of the upper limb (UL) is related to exercise intensity, defined as movement repetitions divided by minutes in active therapy, and task difficulty. However, the degree to which UL training in virtual reality (VR) applications deliver intense and challenging exercise and whether these factors are considered in different centres for people with different sensorimotor impairment levels is not evidenced. We determined if (1) a VR programme can deliver high UL exercise intensity in people with sub-acute stroke across different environments and (2) exercise intensity and difficulty differed among patients with different levels of UL sensorimotor impairment.
Methods: Participants with sub-acute stroke (<6 months) with Fugl-Meyer scores ranging from 14 to 57, completed 10 ∼ 50-min UL training sessions using three unilateral and one bilateral VR activity over 2 weeks in centres located in three countries. Training time, number of movement repetitions, and success rates were extracted from game activity logs. Exercise intensity was calculated for each participant, related to UL impairment, and compared between centres.
Results: Exercise intensity was high and was progressed similarly in all centres. Participants had most difficulty with bilateral and lateral reaching activities. Exercise intensity was not, while success rate of only one unilateral activity was related to UL severity.
Conclusion: The level of intensity attained with this VR exercise programme was higher than that reported in current stroke therapy practice. Although progression through different activity levels was similar between centres, clearer guidelines for exercise progression should be provided by the VR application.
- Implications for rehabilitation
VR rehabilitation systems can be used to deliver intensive exercise programmes.
VR rehabilitation systems need to be designed with measurable progressions through difficulty levels.
[ARTICLE] Nervous System Pathophysiology: A critical time window for recovery extends beyond one-year post-stroke. – Full Text
The impact of rehabilitation on post-stroke motor recovery and its dependency on the patient’s chronicity remain unclear. The field has widely accepted the notion of a proportional recovery rule with a “critical window for recovery” within the first 3–6 mo poststroke. This hypothesis justifies the general cessation of physical therapy at chronic stages. However, the limits of this critical window have, so far, been poorly defined. In this analysis, we address this question, and we further explore the temporal structure of motor recovery using individual patient data from a homogeneous sample of 219 individuals with mild to moderate upper-limb hemiparesis. We observed that improvement in body function and structure was possible even at late chronic stages. A bootstrapping analysis revealed a gradient of enhanced sensitivity to treatment that extended beyond 12 mo poststroke. Clinical guidelines for rehabilitation should be revised in the context of this temporal structure.
NEW & NOTEWORTHY Previous studies in humans suggest that there is a 3- to 6-mo “critical window” of heightened neuroplasticity poststroke. We analyze the temporal structure of recovery in patients with hemiparesis and uncover a precise gradient of enhanced sensitivity to treatment that expands far beyond the limits of the so-called critical window. These findings highlight the need for providing therapy to patients at the chronic and late chronic stages.
The absolute incidence of stroke will continue to rise globally with a predicted 12 million stroke deaths in 2030 and 60 million stroke survivors worldwide (Eilers 2003). Stroke leads to focal lesions in the brain due to cell death following hypoxia and inflammation, affecting both gray and white matter tracts (Corbetta et al. 2015). After a stroke, a wide range of deficits can occur with varying onset latencies such as hemiparesis, abnormal posture, spatial hemineglect, aphasia, and spasticity, along with affective and cognitive deficits, chronic pain, and depression (Teasell et al. 2003). Due to improved treatment procedures during the acute stage of stroke (e.g., thrombolysis and thrombectomy), the associated reduction in stroke mortality has led to a greater proportion of patients facing impairments and needing long-term care and rehabilitation. However, prevention, diagnostics, rehabilitation, and prognostics of stroke recovery have not kept pace (Veerbeek et al. 2014).
Motor recovery after stroke has been widely operationalized as the individual’s change in two domains: 1) body function and structure (WHO 2001), whose improvement has been called “true recovery” (Bernhardt et al. 2017) and refers to the restitution of a movement repertoire that the individual had before the injury; and 2) the ability to successfully perform the activities of daily living (Levin et al. 2009). While the former is mainly due to the interaction of poststroke plasticity mechanisms and sensorimotor training, the latter is also influenced by the use of explicit and implicit compensatory strategies (Bernhardt et al. 2017; Kwakkel et al. 2017). The most accepted measure for recovery of body function and structure is the change in the Fugl-Meyer Assessment of the upper extremity (UE-FM) scores (Kwakkel et al. 2017), while other clinical scales focus on the assessment of activities, such as the Chedoke Arm and Hand Activity Inventory (CAHAI) (Barreca et al. 2005) or the Barthel Index for Activities of Daily Living (BI) (Granger et al. 1979).
Poststroke motor recovery mostly follows a nonlinear trajectory that reaches asymptotic levels a few months after the injury (Kwakkel et al. 2004). This model suggests the existence of a period of heightened plasticity in which the patient seems to be more responsive to treatment, the so-called “critical window” for recovery. Aiming at characterizing the temporal structure of recovery, animal models and clinical research have identified a combination of mechanisms underlying neurological repair that seems to be unique to the injured brain, including neurogenesis, gliogenesis, axonal sprouting, and the rebalancing of excitation and inhibition in cortical networks (Ward 2017). This state of enhanced plasticity seems to be transient and interacts closely with sensorimotor training to facilitate the recovery of motor function (Zeiler et al. 2016). However, there is no clear evidence of the exact temporal structure of enhanced responsiveness to treatment in humans, and as a result the optimal timing and intensity of treatment remain unclear. A systematic review of 14 studies suggested that, on average, recovery reaches a plateau at 15 wk poststroke for patients with severe hemiparesis and at 6.5 wk for patients with mild hemiparesis (Hendricks et al. 2002). This study however failed to conduct a meta-analysis due to substantial heterogeneity of the sample and protocols. Currently, an ongoing clinical trial is investigating the existence and the duration of a critical window of enhanced neuroplasticity in humans following ischemic stroke (McDonnell et al. 2015). Based on the assumption of the existence of this critical period, the SMARTS 2 trial (NCT02292251) (Krakauer and Cortés 2018) is currently investigating the effect of early and intensive therapy on upper extremity motor recovery. Sharing the same research question, the Critical Periods After Stroke Study (CPASS) is a large ongoing randomized controlled trial that focuses on determining the optimal time after stroke for intensive motor training (Dromerick et al. 2015). To contribute to the delineation of a temporal structure of stroke recovery in humans, we performed an analysis of individual patient clinical data from 219 subjects with upper-limb hemiparesis, who followed occupational therapy (OT) or a virtual reality (VR)-based training protocol using the Rehabilitation Gaming System (RGS) (Cameirão et al. 2010) (Fig. S1 in Supplemental Material; all Supplemental material is available at https://doi.org/10.5281/zenodo.3246368). We show that physical therapy has a significant impact on the function of the upper extremity (UE) at all periods poststroke considered, uncovering a gradient of responsiveness to treatment that extends >12 mo poststroke.[…]
[Abstract] The Use of Virtual Reality Applications in Stroke Rehabilitation for Older Adults : Technology Enhanced Relearning
After stroke rehabilitation is a long-term relearning process that can be divided into cognitive relearning, speech relearning and motoric relearning. Today with an aging population it it interesting to look at technology enhanced and game-based solutions that can facilitate independent living for older adults. The aim of the study was to identify and categorise recently conducted research in the field of virtual reality applications for older adults’ relearning after stroke. This study was conducted as a systematic literature review with results categorised in a pre-defined framework. Findings indicate that virtual reality-based stroke rehabilitation is an emerging field that can renew after stroke rehabilitation. Most found studies were on stroke patients’ motoric and game-based relearning, and with less studies on speech rehabilitation. The conclusion is that virtual reality systems should not replace the existing stroke rehabilitation, but rather to have the idea of combining and extending the traditional relearning process where human-to-human interaction is essential. Finally, there are no virtual reality applications that can fit all stroke patients’ needs, but a thoughtful selection of exercises that matches each individual user would have a potential to enhance the current relearning therapy for older adults after stroke.
[Abstract] Examining the effect of virtual reality therapy on cognition post-stroke: a systematic review and meta-analysis
Introduction: Virtual reality (VR) are user-computer interface platforms that implement real-time simulation of an activity or environment, allowing user interaction via multiple sensory modalities. VR therapy may be an effective intervention for improving cognitive function following stroke. The aim of this systematic review was to examine the effectiveness of exercise-based VR therapy on cognition post-stroke.
Methods: Electronic databases were searched for terms related to “stroke”, “virtual reality”, “exercise” and “cognition”. Studies were included if they: (1) were randomized-controlled trials; (2) included VR-based interventions; (3) included individuals with stroke; and (4) included outcome measures related to cognitive function. Data from included studies were synthesised qualitatively and where possible, random effects meta-analyses were performed.
Results: Eight studies involving 196 participants were included in the review, of which five were included in meta-analyses (n = 124 participants). Studies varied in terms of type (combination of VR therapy and conventional therapy, combination of VR therapy and computer-based cognitive training, VR therapy alone) and duration of interventions (20–180 min), sample size (n = 12–42), length of the interventions (4–8 weeks), and cognitive outcomes examined. VR therapy was not more effective than control for improving global cognition (n = 5, SMD = 0.24, 95%CI:−0.30,0.78, p = .38), memory (n = 2 studies, SMD= 0.00, 95%CI: −0.58, 0.59, p = .99), attention (n = 2 studies, MD = 8.90, 95%CI: −27.89, 45.70, p = .64) or language (n = 2 studies, SMD = 0.56, 95%CI: −0.08,1.21, p = .09).
Conclusion: VR therapy was not superior to control interventions in improving cognition in individuals with stroke. Future research should include high-quality and adequately powered trials examining the impact of virtual reality therapy on cognition post-stroke.
Implications for rehabilitation
Virtual reality therapy is a promising new form of technology that has been shown to increase patient satisfaction towards stroke rehabilitation.
Virtual reality therapy has the added benefits of providing instant feedback, and the difficulty can be easily modified, underscoring the user-friendliness of this form of rehabilitation.
Virtual reality therapy has the potential to improve various motor, cognitive and physical deficits following stroke, highlighting its usefulness in rehabilitation settings.
[ARTICLE] Transfer of motor skill between virtual reality viewed using a head-mounted display and conventional screen environments – Full Text
Virtual reality viewed using a head-mounted display (HMD-VR) has the potential to be a useful tool for motor learning and rehabilitation. However, when developing tools for these purposes, it is important to design applications that will effectively transfer to the real world. Therefore, it is essential to understand whether motor skills transfer between HMD-VR and conventional screen-based environments and what factors predict transfer.
We randomized 70 healthy participants into two groups. Both groups trained on a well-established measure of motor skill acquisition, the Sequential Visual Isometric Pinch Task (SVIPT), either in HMD-VR or in a conventional environment (i.e., computer screen). We then tested whether the motor skills transferred from HMD-VR to the computer screen, and vice versa. After the completion of the experiment, participants responded to questions relating to their presence in their respective training environment, age, gender, video game use, and previous HMD-VR experience. Using multivariate and univariate linear regression, we then examined whether any personal factors from the questionnaires predicted individual differences in motor skill transfer between environments.
Our results suggest that motor skill acquisition of this task occurs at the same rate in both HMD-VR and conventional screen environments. However, the motor skills acquired in HMD-VR did not transfer to the screen environment. While this decrease in motor skill performance when moving to the screen environment was not significantly predicted by self-reported factors, there were trends for correlations with presence and previous HMD-VR experience. Conversely, motor skills acquired in a conventional screen environment not only transferred but improved in HMD-VR, and this increase in motor skill performance could be predicted by self-reported factors of presence, gender, age and video game use.
These findings suggest that personal factors may predict who is likely to have better transfer of motor skill to and from HMD-VR. Future work should examine whether these and other predictors (i.e., additional personal factors such as immersive tendencies and task-specific factors such as fidelity or feedback) also apply to motor skill transfer from HMD-VR to more dynamic physical environments.
The use of virtual reality (VR) in rehabilitation has been growing exponentially over recent years [1, 2]. Clinical applications of VR have been shown to be engaging and motivating [3, 4] with promising results suggesting VR interventions are comparable  or in some cases superior [6, 7] to conventional rehabilitation. However, while a number of studies have reported benefits of using VR for cognitive and motor rehabilitation, there are also reports on the limitations of using these devices for clinical applications [8, 9]. In particular, some studies have shown that VR interventions are not effective at improving motor performance in the real world due to a lack of motor skill transfer (i.e., the application of a motor skill in a novel task or environment ) [11, 12].
Concerns about motor skill transfer from virtual to real environments are even greater when specifically considering the use of VR viewed using a head-mounted display (HMD-VR). HMD-VR provides a more immersive experience compared to conventional environments (e.g., computer screens) and results in increased levels of presence (i.e., the illusion of actually being present in the virtual environment) and embodiment (i.e., the perceptual ownership of a virtual body in a virtual space) [13, 14] that modulate behavior  and impact performance on motor learning and rehabilitation applications (e.g., gait, balance, neurofeedback tasks) [16,17,18]. Additionally, motor learning in HMD-VR (e.g., upper extremity visuomotor adaptation) has been shown to rely on different learning processes compared to a conventional screen environment . Given the differences in immersive experiences and learning processes between HMD-VR and conventional environments, it can be assumed that individuals may experience these environments as separate contexts. Studies have found the context of the training environment to affect the transfer of motor skills , where motor performance may decrease when testing occurs in an environment different from training . However, only a small number of studies have specifically explored motor skill transfer of from an HMD-VR training environment to a more conventional environment (e.g., computer screen or real world) [22,23,24,25,26]. Among these studies, there are again conflicting results, with some studies finding successful motor skill transfer from HMD-VR to the real world [22, 23], and others not [24,25,26].
There is also large interindividual variability within the results, and this variability suggests there may be particular tasks or particular individuals that will be more successful in transferring HMD-VR motor skills to the real world. Understanding the task-related or personal factors that mediate learning and transfer from HMD-VR environments should be examined in order to understand what makes HMD-VR interventions effective. One advantage of HMD-VR over conventional screen environments is the ability to realistically simulate the real world which allows for greater task specificity . Task-related factors such as fidelity (i.e., imitation of the real environment) and dimensionality (i.e., matching dimensions between virtual and real environments) between HMD-VR and the real world have been shown to influence lower extremity motor performance  and have been suggested to have an influence on transfer in both lower and upper extremity motor transfer [29, 30]. Individual differences in personal factors such as gender, age, video game experience, prior technical computer literacy, and computer efficacy seemed to influence transfer from HMD-VR to the real world in studies examining the transfer of spatial knowledge acquired in an HMD-VR environment [26, 31]. However, the individual differences on both task-related and personal factors have not been extensively examined in HMD-VR motor skill transfer. We begin to address this gap by examining whether individual personal factors facilitate better transfer from upper extremity motor skill acquisition in HMD-VR to a conventional screen environment.
In the current study, we examined: (1) whether transfer of upper extremity motor skills occurs between HMD-VR and conventional screen environments, and (2) what personal factors predict transfer between environments. Given the variability of motor skill learning and transfer in previous studies [22,23,24,25,26, 29], we hypothesized that individual motor performance would vary after transfer to a novel environment, and that this variability could be predicted by individual differences in variables such as presence in the training environment, prior experience with HMD-VR, or non-VR video games.
Methods and materials
Seventy-four healthy adults were recruited. Participants were randomized into two groups (Train-HMD-VR, Train-Screen). Three participants in the Train-Screen group were excluded from the analysis as a result of performing all trials in the Baseline training block incorrectly (see Analyses) and one participant in the Train-HMD-VR group was excluded from the analysis as a result of being an outlier, which was defined as being beyond three standard deviations from the group mean motor skill in at least one of the blocks. This resulted in a total of seventy participants (53 females/16 males/1 other, aged: M = 25.81, SD = 4.71) with thirty-five participants in each group included in the analysis. A statistical power analysis was performed for sample size estimation based on data from a pilot study of this work (N = 12) . The effect size in this study was d = 0.38. With an alpha = 0.05 and power = 0.60, the projected sample size need with this effect size was approximately N = 35. Eligibility criteria included healthy, self-reported right-handed individuals and no previous experience with the motor skill task (see Experimental design). Written informed consent was obtained from all subjects. The experimental protocol was approved by the University of Southern California Institutional Review Board and performed in accordance with the 1964 Declaration of Helsinki.
Figure 1a provides an overview of the experimental design. The experiment consisted of training and testing blocks in which participants completed a modified version of the Sequential Visual Isometric Pinch Task (SVIPT) . In this task, participants were instructed to apply varying degrees of isometric force between their thumb and index finger to a small pinch force sensor (Futek Pinch Sensor FSH01465; Futek IPM FSH03633; Fig. 1b) to move a cursor between numbered colored gates as quickly and accurately as possible (Fig. 1c). A small circle at the bottom of the screen changed from red to green to indicate the start of each trial. For each trial, no time limit was given and trial completion time was recorded. At the end of each trial, the small circle at the bottom of the screen changed from green to red and participants received auditory feedback (a pleasant “ding” if the cursor correctly entered all the gates or an unpleasant “buzz” if the cursor missed one or more of the gates). A two-second time interval was given between each trial.