Posts Tagged VR

[WEB SITE] Benefits of Virtual Reality for Stroke Rehabilitation – Saebo

Virtual reality (VR) is the new must-have technology tool for gaming, training, or just trying to immerse yourself in a new and virtual environment. From Google Cardboard to Oculus Rift, this technology is becoming more and more accessible to the everyday person. Now anyone can put on a headset and suddenly be transported to a world where they have full control and no consequences.

VR technology isn’t just useful for gaming. It has been shown to help in a variety of applications, from military training activities to treatment for anxiety disorders and phobias to functioning as an art form. Another application where VR shows a lot of promise is stroke recovery.

Virtual Reality and Stroke Recovery

Virtual Reality has emerged as a new approach to treatment in stroke rehabilitation settings over the last ten years. By simulating real-life activities, stroke patients are able to work on self-care skills in a setting that is usually impossible to create in a hospital environment.

There are two main types of VR:

Immersive

In immersive VR, the virtual environment is delivered by equipment worn by the user (like goggles) or the person is situated within a virtual environment. This fully immersive system gives the user a strong sense of presence through the use of head-mounted displays, special gloves, and large, concave screen projections to create the sense of immersion.

Non-Immersive

Non-immersive VR is usually two-dimensional and delivered through a computer screen. The user can control what is happening on screen by using a device such as a joystick, mouse, or sensor.

After a stroke, mass practice, task-oriented arm training of the upper and lower limbs can help the brain “re-program” itself and form new neural connections. These new connections stimulate recovery of motor skills in patients following stroke. So VR may be useful to augment rehabilitation of the upper and lower limbs in patients suffering from stroke and other neurological injuries.

In some studies, therapists have manipulated the image onscreen to make the patient’s limb appear to be moving faster and more accurately than it was in real life. Doing this increased the patient’s confidence and made them more likely to use their affected limb spontaneously. Spontaneous use of the affected limb can help the limb recover more completely.

SaeboVR

SaeboVR is the world’s only virtual rehabilitation system exclusively focusing on ADL’s (activities of daily living). The proprietary platform was specifically designed to engage clients in both physical and cognitive challenges involving daily functional activities. In addition to interacting with meaningful every-day tasks, the SaeboVR uses a virtual assistant that appears on the screen to educate and facilitate performance by providing real-time feedback.

 

 

SaeboVR’s ADL-focused virtual world provides clients with real-life challenges. Users will incorporate their impaired upper limb to perform simulated self-care tasks that involve picking up, transferring, and manipulating virtual objects.

 

Why SaeboVR?

  • It’s the only virtual system available that focuses on real-life self-care tasks.
  • Let’s you practice repetitive movements with fun and motivating activities.
  • Activities are adaptable to the individual client to maximize success and outcomes.
  • ADL tasks can be customized to challenge endurance, speed, range of motion, coordination, timing, and cognitive demand.
  • It includes a clinical provider dashboard to view client performance and participation trends.
  • Reports are graphically displayed for easy viewing.

Saebo’s other products can also be used in conjunction with the SaeboVR to facilitate recovery. The SaeboMAS and SaeboMAS mini use unweighting technology that will allow clients with proximal weakness to participate in proven treatment techniques that would otherwise have been impossible. The SaeboGlove can engage and position the hand so it can be incorporated in virtual grasp-and-release activities.

The Future of Stroke Rehabilitation

Virtual reality is here to stay, and we have likely only scratched the surface of its medical applications. It’s having a powerful impact on those who have had strokes. Stroke survivors are taking advantage of how VR enables them to practice necessary routine activities, create new connections in the brain, and build up their confidence. With more and more survivors retraining their limbs using this technology, the future of VR in stroke recovery looks bright.

 

All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.

Source: Benefits of Virtual Reality for Stroke Rehabilitation | Saebo

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[WHITE PAPER] Virtual and augmented reality based balance and gait training – Full Text PDF

The use of virtual and augmented reality for rehabilitation has become increasingly popular and has received much attention in scientific publications (over 1,000 papers). This white paper aims to summarize the scientific background and efficacy of using virtual and augmented reality for balance and gait training. For many patients with movement disorders, balance and gait training is an important aspect of their rehabilitation process and physical therapy treatment. Indications for such training include, among others, stroke, Parkinson’s disease, multiple sclerosis, cerebral palsy, vestibular disorders, neuromuscular diseases, low back pain, and various orthopedic complaints, such as total hip or knee replacement. Current clinical practice for balance training include exercises, such as standing on one leg, wobble board exercises and standing with eyes closed. Gait is often trained with a treadmill or using an obstacle course. Cognitive elements can be added by asking the patient to simultaneously perform a cognitive task, such as counting down by sevens. Although conventional physical therapy has proven to be effective in improving balance and gait,1,2 there are certain limitations that may compromise treatment effects. Motor learning research has revealed some important concepts to optimize rehabilitation: an external focus of attention, implicit learning, variable practice, training intensity, task specificity, and feedback on performance.3 Complying with these motor learning principles using conventional methods is quite challenging. For example, there are only a limited number of exercises, making it difficult to tailor training intensity and provide sufficient variation. Moreover, performance measures are not available and thus the patient usually receives little or no feedback. Also, increasing task specificity by simulating everyday tasks, such as walking on a crowded street, can be difficult and time consuming. Virtual and augmented reality could provide the tools needed to overcome these challenges in conventional therapy. The difference between virtual and augmented reality is that virtual reality offers a virtual world that is separate from the real world, while augmented reality offers virtual elements as an overlay to the real world (for example virtual stepping stones projected on the floor). In the first part of this paper we will explain the different motor learning principles, and how virtual and augmented reality based exercise could help to incorporate these principles into clinical practice. In the second part we will summarize the scientific evidence regarding the efficacy of virtual reality based balance and gait training for clinical rehabilitation.

Full Text PDF

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[WEB SITE] Is Clinical Virtual Reality the Future of Therapy?

Image courtesy of Pixabay.

As the meteors came down from the sky, my heart thudded in my chest. There was only one way I could save the town below: Reach out into the air, make a fist, and in doing so, set off an explosion. And then another. And another. How else can one be expected to defend a village?

This was the task given to me by Alex Miller, a computer scientist creating virtual realities for the neurology department at the University of Pennsylvania. Under the guidance of Dr. Branch Coslett, Miller’s lab is making programs for stroke victims trying to regain the use of a limb, amputees trying to lose phantom limb pain, and other people with mysterious, hard-to-heal conditions of the body and brain.

Missile Command. Image courtesy of Alex Miller, University of Pennsylvania.

But in the meantime, I’m strapped into an Oculus Rift VR headset, with a Leap Motion tracking system attached to the front of it. The Leap Motion is, well, magical: it scans the area in front of it, registers where my hands are, and then projects those hands into the game. The experience is profoundly immersive: when I move my head left or right, the view in the game moves accordingly, and if I open my hand or close my wrist, the same happens in-game, in real-time. There are many possible medical applications: the game is recording all of my movements, creating what would be a hyper-detailed tracking of rehab progress over time, and if Miller so chose, my in-game left hand could be a representation of my real-life right hand—a fun trick for an able-bodied person, but if I had lost my left hand, my brain seeing an intact left hand in game could actually ease phantom limb pain.

Just a few minutes earlier, Miller was strapping sensors to my thighs and knees. I’m in yet another world, and with my virtual feet underneath me. I’m on a platform in a desert, it’s twilight, and I have a puzzle to solve: make it from my spawning point to a glowing goal across the way. There are any number of pits I need to avoid falling into, and in classic game fashion, the solution is to push crates into them. Seated in my chair, I make a slow, dragging step to move forward, and sweep my foot left or right to turn. The sensors strapped to me are set up so that if you had lost your leg below—or above—the knee, the electronic signals sent by the muscles would be detected, and you’d make those same movements in the game. So even for a body that is injured in real life, it can be intact in the game, and neurologically speaking, it doesn’t make that much of a difference.

“That’s the killer use case of virtual reality,” Miller explains. The brain is surprisingly easy to fool, and it will believe that the hands and feet in a game are your own, with potentially huge medical consequences. “It’s really about illusion,” he says: you manipulate what a patient sees in their virtual self and their virtual world, and their brains will literally incorporate these things into the body image. While still early, results indicate that using the Penn neurology games does indeed reduce the intensity of phantom limb pain.

Kicking around virtual boxes. Image courtesy of Alex Miller, University of Pennsylvania.

The idea of virtual reality has been around for decades. The French dramatist Antonin Artaud coined “la realite virtuelle” in 1938 to describe the temporary world created by theatre. The 1960s saw the Sensorama, an arcade cabinet that played 3D movies along with stereo sound, wind and smells on head-mounted displays. Movies like TronThe Lawnmower Man and The Matrix all help make VR a household term. And the 1990s saw a boom in VR arcades, with game console manufacturers making early bids, too—shoutout to Nintendo’s Virtual Boy. The first examples of medical VR started showing up then, too—like a demo of gastrointestinal surgery. But, according to many researchers Thrive Global spoke to, we’ve entered a new era of VR in just the past few years.

With the Oculus, the HTC Vive, and other VR setups becoming available, the price of setting up a VR lab has cratered: Betty Mohler, a researcher at the Max Planck Institute for Biological Cybernetics, tells Thrive Global the cost has fallen a hundredfold. And it’s getting even cheaper, as low-cost options like the Google Daydream start rolling out. “With affordable, high-quality virtual reality devices hitting the market for the first time, the future seems suddenly imminent,” Oxford psychiatrist and VR specialist Daniel Freeman tells Thrive Global. “VR could become the method of choice for psychological treatment — out with the couch, on with the headset.”

It’s a potential that the investors have seen, most famously with Facebook’s $3 billionpurchase of Oculus in 2014. More recently, with the growing hype surrounding MindMaze, a VR startup out of Switzerland with a valuation already north of $1 billion. The company’s stroke rehab treatments were introduced into European hospitals in 2013, and the company announced entry into the US market this year. Since VR is so stimulating, patients are more likely to do their rehab, and according to one company report, a full 100 percent of patients forgot they were in the hospital while doing their VR rehab.

VR is simultaneously neurological and psychological: it has applications with disorders of the body, like phantom limb pain, and conditions of the mind, like PTSD, anxiety, and paranoia. Unlike any other technology before it, VR gives the user a direct sense of embodiment, what University of Barcelona pioneer Mel Slater refers to as “presence.” It’s not just another medium in a long line of media: virtual reality directly accesses people’s sense of self—these hands are mine, my own brain thought, as I pawed at the meteors. Rather than flatly watching, you’re immersed in the virtual world.

The thing about conventional “talk” therapy is that all the therapist and the client can really do is remember and imagine: you might get tips about how to keep your family from driving you crazy the next time Thanksgiving rolls around, but your shrink can’t place you at the dinner table. That all changes with virtual reality: with the right software, a therapist can put you in the places you have come to fear the most. People with arachnophobia get anxious around spiders, those with paranoia are afraid of social situations, and people with PTSD get triggered by cues linked to their trauma.

“Difficulties interacting in the world are at the heart of mental health issues,” Freeman, the Oxford psychiatrist, explains. With VR, you can repeatedly experience those feared situations—at a just-tolerable dose—and learn to overcome them. “The beauty of VR is that individuals know that a computer environment is not real, but their minds and bodies behave as if it is real,” he adds, which allows people to more easily face fearful situations, and then experiment with how to approach them. “This learning then transfers to the real world,” he says.

His lab has done lots of research around paranoia, a condition that affects around 1 or 2 percent of the population. In a 2016 paper in the British Journal of Psychiatry, Freeman and his team dropped people with paranoia into public situations, like standing in an elevator or commuting on a subway car. The subjects wore headsets and could walk around a room, rather than using a controller. Every time the patient entered one of these levels, they’d encounter more people in that space. After doing just 30 minutes of VR, about half of the patients no longer felt severe paranoia at the end of their testing day, and when they went into real social situations, they felt less distressed.[…]

Visit site —> Is Clinical Virtual Reality the Future of Therapy? | Thrive Global

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

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

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

 

Abstract

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

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

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

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

1. Introduction

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

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

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

2. Technological devices for upper limb rehabilitation

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

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

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

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

3. Experimental design

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

3.1. Participants description

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

3.2. Device description

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

3.3. Study protocol

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

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

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

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

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

4. Results and discussion

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

Stroke (average in mm) Traumatic brain injury (average in mm)
Range of motion (flexo-extension)
Wrist
Little
Ring
Middle
Index
Thumb
Active

8
11
14.3
11
10
8.3
Passive

23
20.3
22.6
22.6
22.6
20.6
Active

18
9
10
9
8
10
Passive

20
14
14
11
17
16
Active flexion deficit
Wrist
Little
Ring
Middle
Index
Thumb

9
5.6
5
4.3
5.6
9

2
0
0
2
0
1
Active extension deficit
Wrist
Little
Ring
Middle
Index
Thumb

6
3.3
3.3
8.4
7
3.3

0
5
4
0
9
5
Treatments sessions log
Reaction speed
Accuracy
Time in seconds (half)
Number of objects
Primary ranger

10
Full
240
1
Full

10
Full
240
1
Full

Table 1.

Hand ROM evaluation pre-session and treatments sessions log.

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

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

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

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

media/F1.png

Figure 1.

Hand ROM evaluation (active).

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Figure 2.

Hand ROM evaluation HandTutor® (passive and active).

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

media/F3.png

Figure 3.

Flexo-extension hand with HandTutor®.

media/F4.png

Figure 4.

Example of assisted movement with HandTutor®.

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

media/F5.png

Figure 5.

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

media/F6.png

Figure 6.

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

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

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

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

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

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

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

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

media/F7.png

Figure 7.

Spastic hand with HandTutor®.

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

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

5. Conclusions

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

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

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

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

6. Acknowledgements

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

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

Abstract

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

This information is relevant for the purpose of

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

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

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

References

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

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[ARTICLE] Using Xbox kinect motion capture technology to improve clinical rehabilitation outcomes for balance and cardiovascular health in an individual with chronic TBI – Full Text

Abstract

Background

Motion capture virtual reality-based rehabilitation has become more common. However, therapists face challenges to the implementation of virtual reality (VR) in clinical settings. Use of motion capture technology such as the Xbox Kinect may provide a useful rehabilitation tool for the treatment of postural instability and cardiovascular deconditioning in individuals with chronic severe traumatic brain injury (TBI). The primary purpose of this study was to evaluate the effects of a Kinect-based VR intervention using commercially available motion capture games on balance outcomes for an individual with chronic TBI. The secondary purpose was to assess the feasibility of this intervention for eliciting cardiovascular adaptations.

Methods

A single system experimental design (n = 1) was utilized, which included baseline, intervention, and retention phases. Repeated measures were used to evaluate the effects of an 8-week supervised exercise intervention using two Xbox One Kinect games. Balance was characterized using the dynamic gait index (DGI), functional reach test (FRT), and Limits of Stability (LOS) test on the NeuroCom Balance Master. The LOS assesses end-point excursion (EPE), maximal excursion (MXE), and directional control (DCL) during weight-shifting tasks. Cardiovascular and activity measures were characterized by heart rate at the end of exercise (HRe), total gameplay time (TAT), and time spent in a therapeutic heart rate (TTR) during the Kinect intervention. Chi-square and ANOVA testing were used to analyze the data.

Results

Dynamic balance, characterized by the DGI, increased during the intervention phase χ 2 (1, N = 12) = 12, p = .001. Static balance, characterized by the FRT showed no significant changes. The EPE increased during the intervention phase in the backward direction χ 2 (1, N = 12) = 5.6, p = .02, and notable improvements of DCL were demonstrated in all directions. HRe (F (2,174) = 29.65, p = < .001) and time in a TTR (F (2, 12) = 4.19, p = .04) decreased over the course of the intervention phase.

Conclusions

Use of a supervised Kinect-based program that incorporated commercial games improved dynamic balance for an individual post severe TBI. Additionally, moderate cardiovascular activity was achieved through motion capture gaming. Further studies appear warranted to determine the potential therapeutic utility of commercial VR games in this patient population.

Trial registration

Clinicaltrial.gov ID – NCT02889289

Background

The last two decades demonstrated an exponential trend in the implementation of virtual reality (VR) in clinical settings [1]. Researchers and clinicians alike are enticed by the potential of this technology to enhance neuroplasticity secondary to rehabilitation interventions. Currently, Nintendo Wii, Sony PlayStation, and Microsoft Xbox offer commercially developed semi-immersive VR platforms which are used for rehabilitation [2]. Several studies report positive effects of these commercial technologies for improving balance, coordination and strength [345]. In 2010, Microsoft introduced a novel infrared camera that works on the Xbox platform called Kinect. The Kinect camera replaces hand held remote controls through the use of whole body motion capture technology.

Whole body motion capture VR allows a unique opportunity for individuals to experience a heightened sense of realism during task-specific therapeutic activities. However, clinicians need to be able to match a game’s components to an individual’s functional deficits. Seamon et al. [6] provided a clinical demonstration of how the Kinect platform can be used with Gentiles taxonomy for progressively challenging postural stability and influencing motor learning in a patient with progressive supranuclear palsy. Similarly, Levac et al. [7] developed a clinical framework titled, “Kinecting with Clinicians” (KWiC) to broadly address implementation barriers. The KWiC resource describes mini-games from Kinect Adventures on the Xbox 360 in order to provide a comprehensive document for clinicians to reference. Clinicians can use KWiC to base game selection and play on their client’s goals and the therapist’s plan of care for that individual.

In parallel with knowledge translation research, several studies found postural control improvements in multiple diagnostic groups including individuals with chronic stroke [8910], Friedrich’s Ataxia [11], multiple sclerosis [12], Parkinson’s disease [13], and mild to moderate traumatic brain injury (TBI) [14] when using Kinect based rehabilitation. Additional research shows that exercising with the Kinect system can reach an appropriate intensity for cardiovascular adaptation. For example, Neves et al. [15] and Salonini et al. [16] reported increases in exercise heart rate and blood pressure in healthy individuals and children with cystic fibrosis while playing Kinect games. Similarly, Kafri et al. [17] reported the ability of individuals post-stroke to reach levels of light to moderate intensity using Kinect games.

Individuals with TBI are likely to have a peak aerobic capacity 65–74% to that of healthy control subjects [18]. There is limited research on cardiovascular training after severe TBI [18]. However, Bateman et al. [19] demonstrated that individuals with severe TBI can improve cardiovascular fitness during a 12-week program participants exercised at an intensity equal to 60–80% of their maximum heart rate 3 days per week. Commercial Xbox Kinect games, such as Just Dance 3, have been shown to improve cardiovascular outcomes for individuals with chronic stroke [20]. However, there is a lack of research investigating the efficacy of motion capture VR on cardiovascular health for individuals with chronic severe TBI. Walker et al. [21] makes the recommendation for rehabilitation programs to go beyond independence in basic mobility and to develop treatment strategies to address high-level physical activities. The high rates of sedentary behavior in individuals across all severities of TBI could be attributed the lack of addressing these limitations in activity.

Postural instability is the second most frequent, self-reported limitation, 5 years post injury for individuals with severe TBI [22]. It is unknown whether use of motion capture VR in individuals with severe, chronic TBI can address neuromotor impairments related to high-level activities such as maintaining postural control during walking. Similarly, there is a need to determine if training with VR motion capture can attain necessary intensity levels for inducing cardiovascular adaptation. Due to this knowledge gap and heterogencity of individuals post TBI, feasibility of investigatory interventions should be explored prior to examining effectiveness with randomized control trials. Single system experimental design (SSED) provides a higher level of rigor compared to case studies based on the ability to compare outcomes across phase conditions with the participant acting as their own control. The value of SSED within rehabilitation has been noted by other investigators [2324] making it an attractive design for practitioners aiming to gain insight into novel clinical interventions prior to large scale clinical trials. The purpose of this proof of concept and feasibility study was to evaluate the effectiveness of commercially available Xbox One Kinect games as a treatment modality for the rehabilitation of balance and cardiovascular fitness for a veteran with chronic severe TBI. Additionally, we provide herein a description of the Kinect games to assist providers with clinical implementation. […]

Continue —>  Using Xbox kinect motion capture technology to improve clinical rehabilitation outcomes for balance and cardiovascular health in an individual with chronic TBI | Archives of Physiotherapy | Full Text

 

Fig. 1 Dynamic gait index (DGI) scores across phases with celeration line analyses. Two-standard deviation (2 SD) celeration line was used for chi-square analysis between baseline and intervention phases as no trend present in baseline phase. The celeration line was carried through the retention phase for Chi-square analysis due to presence of upward trend in intervention phase

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[Abstract + References] Virtual fine rehabilitation in patients with carpal tunnel syndrome using low-cost devices

Carpal tunnel syndrome (CTS) happens when there is a compression of the median nerve between the forearm and the hand. This disorder causes an influence on basic and instrumental Activities of Daily Living. The motor disruptions are muscle weakness, tingling, and heaviness in the hand. The main disorder which subjects suffer with CTS is pain. To alleviate or mitigate pain in CTS, there are different techniques such as pharmacologic treatments, splints to immobilize the wrist, surgery, and physical therapy. Novel and customizable low-cost devices together with Virtual Environments are a good complement in rehabilitation sessions for this syndrome. The aim of this present study is to test a novel system, Virtual Rehabilitation Carpal Tunnel (VRCT), in patients with CTS. For this purpose, we have tested our system with four CTS patients (experimental group). At the same time, four CTS patients were tested using traditional rehabilitation. Phalen and Tinel test were used to analyze the results. The results obtained showed greater improvement in the experimental group during the intervention period. Future research will be focused on the analysis of the follow-up period.

References

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Source: Virtual fine rehabilitation in patients with carpal tunnel syndrome using low-cost devices

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[ARTICLE] Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review – Full Text

Abstract

Background

Virtual reality (VR) based applications play an increasing role in motor rehabilitation. They provide an interactive and individualized environment in addition to increased motivation during motor tasks as well as facilitating motor learning through multimodal sensory information. Several previous studies have shown positive effect of VR-based treatments for lower extremity motor rehabilitation in neurological conditions, but the characteristics of these VR applications have not been systematically investigated. The visual information on the user’s movement in the virtual environment, also called movement visualisation (MV), is a key element of VR-based rehabilitation interventions. The present review proposes categorization of Movement Visualisations of VR-based rehabilitation therapy for neurological conditions and also summarises current research in lower limb application.

Methods

A systematic search of literature on VR-based intervention for gait and balance rehabilitation in neurological conditions was performed in the databases namely; MEDLINE (Ovid), AMED, EMBASE, CINAHL, and PsycInfo. Studies using non-virtual environments or applications to improve cognitive function, activities of daily living, or psychotherapy were excluded. The VR interventions of the included studies were analysed on their MV.

Results

In total 43 publications were selected based on the inclusion criteria. Seven distinct MV groups could be differentiated: indirect MV (N = 13), abstract MV (N = 11), augmented reality MV (N = 9), avatar MV (N = 5), tracking MV (N = 4), combined MV (N = 1), and no MV (N = 2). In two included articles the visualisation conditions included different MV groups within the same study. Additionally, differences in motor performance could not be analysed because of the differences in the study design. Three studies investigated different visualisations within the same MV group and hence limited information can be extracted from one study.

Conclusions

The review demonstrates that individuals’ movements during VR-based motor training can be displayed in different ways. Future studies are necessary to fundamentally explore the nature of this VR information and its effect on motor outcome.

Background

Virtual reality (VR) in neurorehabilitation has emerged as a fairly recent approach that shows great promise to enhance the integration of virtual limbs in one`s body scheme [1] and motor learning in general [2]. Virtual Rehabilitation is a “group [of] all forms of clinical intervention (physical, occupational, cognitive, or psychological) that are based on, or augmented by, the use of Virtual Reality, augmented reality and computing technology. The term applies equally to interventions done locally, or at a distance (tele-rehabilitation)” [3]. The main objectives of intervention for facilitating motor learning within this definition are to (1) provide repetitive and customized high intensity training, (2) relay back information on patients’ performance via multimodal feedback, and (3) improve motivation [24]. VR therapies or interventions are based on real-time motion tracking and computer graphic technologies displaying the patients’ behaviour during a task in a virtual environment.

The interaction of the user and Virtual environment can be described as a perception and action loop [5]. This motor performance is displayed in the virtual environment and subsequently, the system provides multimodal feedback related to movement execution. Through external (e.g. vision) and internal (proprioception) senses the on-line sensory feedback is integrated into the patient’s mental representation. If necessary, the motor plan is corrected in order to achieve the given goal [5].

A previous Cochrane Review from Laver, George, Thomas, Deutsch, and Crotty [2] on Virtual Reality for stroke rehabilitation showed positive effects of VR intervention for motor rehabilitation in people post-stroke. However, grouped analysis from this review on recommendation for VR intervention provides inconclusive evidence. The author further comments that “[…] virtual reality interventions may vary greatly […], it is unclear what characteristics of the intervention are most important” ([2], p. 14).

Virtual rehabilitation system provides three different types of information to the patient: movement visualisation, performance feedback and context information [6]. During a motor task the patient’s movements are captured and represented in the virtual environment (movement visualisation). According to the task success, information about the accomplished goal or a required movement alteration is transmitted through one or several sensory modalities (performance feedback). Finally, these two VR features are embedded in a virtual world (context information) that can vary from a very realistic to an abstract, unrealistic or reduced, technical environment.

Performance feedback often relies on theories of motor learning and is probably the most studied information type within VR-based motor rehabilitation. Moreover, context information is primarily not designed with a therapeutic purpose. Movement observation, however, plays an important role for central sensory stimulation therapies, such as mirror therapy or mental training. The observation or imagination of body movements facilitates motor recovery [789] and provides new possibilities for cortical reorganization and enhancement of functional mobility. Thus, it appears that movement visualisation may also play an important role in motor rehabilitation [101112], although this aspect is yet to be systematically investigated [13].

The main goal of the present review is to identify various movement visualisation groups in VR-based motor interventions for lower extremities, by means of a systematic literature search. Secondarily, the included studies are further analysed for their effect on motor learning. This will help guide future research in rehabilitation using VR.

An interim analysis of the review published in 2013 showed six MV groups for upper and lower extremity training and additional two MV groups directed only towards lower extremity training. In this paper, we analysed only studies involving lower limb training, leading to a revision and expansion of the previously published MV groups findings [131415].

Continue —> Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review | BioMedical Engineering OnLine | Full Text

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[WEB SITE] The Rehabilitation Gaming System

slideshow 1RGS is a highly innovative Virtual Reality (VR) tool for the rehabilitation of deficits that occur after brain lesions and has been successfully used for the rehabilitation of the upper extremities after stroke.
The RGS is based on the neurobiological considerations that plasticity of the brain remains  throughout life and therefore can be utilized to achieve functional reorganization of the brain areas affected by stroke. This can be realized by means of activation of secondary motor areas such as the so called mirror neurons system.

RGS deploys a deficit oriented training approach. Specifically, while training with RGS the patient is playing individualized games where movement execution is combined with the observation of correlated actions performed by a virtual body. The system optimizes the user’s training by analyzing the qualitative and quantitative aspects of the user’s performance. This warranties a detailed assessment of the deficits of the patient and their recovery dynamics.

Key articles and Recent publications

also see specs.upf.edu

Source: The Rehabilitation Gaming System | Rehabilitation Gaming System

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[Research Poster] Upper Limb Virtual Reality Training Provides Increased Activity Compared With Conventional Training for Severely Affected Subacute Patients After Stroke

To compare amount of activity of virtual reality (VR) and conventional task-oriented training (CT).

Source: Upper Limb Virtual Reality Training Provides Increased Activity Compared With Conventional Training for Severely Affected Subacute Patients After Stroke – Archives of Physical Medicine and Rehabilitation

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