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

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

KEY POINTS

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

By Andrew Danso, Ph.D.

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

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

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

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

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

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

• Customisable treatment experiences
• Immersive patient experiences

User testing the virtual reality application

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

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

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

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

References

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

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

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

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

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

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

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

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

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

Abstract

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

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[WEB] The Use of Virtual Reality in Physical Therapy

By Medriva

THE FUTURE IS HERE: LEVERAGING VIRTUAL REALITY IN PHYSICAL THERAPY

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

Understanding Virtual Reality

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

The Emergence of VR in Physical Therapy

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

How Does VR Physiotherapy Work?

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

The Benefits of Using VR in Physical Therapy

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

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

The Future of VR in Physical Therapy

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

Conclusion

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

Source

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

Abstract 

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

Full text links 

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

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

[Abstract + References] Effects of immersive and non-immersive virtual reality-based rehabilitation training on cognition, motor function, and daily functioning in patients with mild cognitive impairment or dementia: A systematic review and meta-analysis

Abstract

Objective

To examine the effectiveness of virtual reality (VR)-based rehabilitation training in improving cognition, motor function, and daily functioning in patients with mild cognitive impairment and dementia.

Data sources

A systematic review of published literature was conducted using PubMed, Web of Science, Elsevier, Embase, Cochrane, CNKI, Networked Digital Library of Theses and Dissertations.

Methods

The search period was from inception to 7 October 2023. Eligible studies were randomized controlled trials evaluating the efficacy of VR-based rehabilitation training in patients with mild cognitive impairment or dementia versus control subjects. Methodologic quality was assessed with the Cochrane risk of bias tool, and outcomes were calculated as the standard mean difference between participant groups with 95% confidence interval.

Results

A total of 21 randomized controlled trials with 1138 patients were included. The meta-analysis showed that VR-based rehabilitation training had significant effects on Montreal Cognitive Assessment (SMD: 0.50; 95%CI: 0.05 to 0.95; P = 0.030), Trail-making test A (SMD: −0.38; 95%CI: −0.61 to −0.14; P = 0.002), and Berg Balance Scale scores (SMD: 0.79; 95%CI: 0.13 to 1.45; P = 0.020). A subgroup analysis revealed that the type of VR, and duration and frequency of interventions had statistically significant effects on cognition and motor function.

Conclusion

VR-based rehabilitation training is a beneficial nonpharmacologic approach for managing mild cognitive impairment or dementia. Immersive VR-based training had greater effects on cognition and motor function than non-immersive VR-based training, but non-immersive VR-based training was more convenient for patients with limitations imposed by their disease. Also, an intervention lasting 5–8 weeks and for >30 min at a frequency of ≥3 times/week achieved the best results. It indicated that a longer intervention cycle may not achieve the best intervention effect and training duration and schedule should be carefully considered when managing patients.

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Source

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

Abstract

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

Keywords: 

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

1. Introduction

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

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

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

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

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

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

2. Materials and Methods

2.1. Participants

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

diagnosis of first-episode stroke,-

age range 40–64,-

acquired motor impairment of hemiplegic upper limb,-

maximum of 12 months period since diagnosis,-

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

Certain exclusion criteria were admitted:-

requirement of constant, intensive medical surveillance,-

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

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

vascular disease (active thromboembolism),-

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

active inflammation,-

uncompensated endocrine disruption,-

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

severe arterial or pulmonary hypertension,-

uncontrolled diabetes,-

epilepsy.

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

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

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

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

2.2. VR Application

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

Figure 1. Oculus Quest 2 module.

[…]

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

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

1 INTRODUCTION

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

2 RELATED WORKS

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

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

3 CONCEPTUAL DESIGN AND GAME PROTOTYPING

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

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

Figure 1: PICO 4 Device

3.1 First Edition

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

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

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[Abstract + References] A new adaptive VR-based exergame for hand rehabilitation after stroke

Abstract

The aim of this work is to present an adaptive serious game based on virtual reality (VR) for functional rehabilitation of the hand after stroke. The game focuses on simulating the palmar grasping exercise commonly used in clinical settings. The system’s design follows a user-centered approach, involving close collaboration with functional rehabilitation specialists and stroke patients. It uses the Leap motion controller to enable patient interaction in the virtual environment, which was created using the Unity 3D game engine. The system relies on hand gestures involving opening and closing movements to interact with virtual objects. It incorporates parameters to objectively measure participants’ performance throughout the game session. These metrics are used to personalize the game’s difficulty to each patient’s motor skills. To do this, we implemented an approach that dynamically adjusts the difficulty of the exergame according to the patient’s performance during the game session. To achieve this, we used an unsupervised machine learning technique known as clustering, in particular using the K-means algorithm. By applying this technique, we were able to classify patients’ performance into distinct groups, enabling us to assess their skill level and adapt the difficulty of the game accordingly. To evaluate the system’s effectiveness and reliability, we conducted a subjective evaluation involving 11 stroke patients. The standardized System Usability Scale (SUS) questionnaire was used to assess the system’s ease of use, while the Intrinsic Motivation Inventory (IMI) was used to evaluate the participants’ subjective experience with the system. Evaluations showed that our proposed system is usable and acceptable on a C-level scale, with a good adjective score, and the patients perceived a high intrinsic motivation.

References

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Source: https://link.springer.com/article/10.1007/s00530-023-01180-0

[Abstract] Exploiting Virtual Reality to Design Exercises for the Recovery of Stroke Patients at Home

Abstract

Stroke affects approximately fifteen million people worldwide annually, with im- paired hand function being one of its most common effects. Hemiparetic post-stroke patients suffer a mild loss of strength involving one side of their body: though not fully debilitating, it still impacts their everyday life activities. To prevent mobility deterioration, patients must perform well-focused and repetitive exercises during chronic rehabilitation. Virtual Reality (VR) emerges as an interesting tool in this framework, offering the possibility of training and measuring the patient’s performances in ecologically valid, engaging, and challenging environments. In recent years, there has been an increasing diffusion of accessible head-mounted displays that enhance the sense of realism and immersion in a virtual scene. To explore the feasibility and efficacy of VR immersion and game mechanics in rehabilitation programs, a VR system that allows users to rehabilitate their motor skills in a home-based environment has been designed and tested considering standard measures related to usability, immersion, workload, and simulator sickness, and with the involvement of rehabilitation experts. The results demonstrate how users and experts have received the application positively, highlighting the potential of VR applications for the future development of home-based rehabilitation programs.

Source: https://re.public.polimi.it/handle/11311/1250780?mode=complete

[Abstract + References] Virtual Reality-Based Rehabilitation for Patients with Stroke: Preliminary Results on User Experience – Conference paper

Abstract

Stroke is one of the major causes of disability worldwide, and most stroke survivors require rehabilitation to recover motor and cognitive functions. Virtual Reality (VR) has emerged as a promising means to administer rehabilitative interventions due to its potential to provide high engagement and motivation, with positive effects on treatment compliance. In this context, we present the Virtual Supermarket (VSS), i.e., an immersive ecological VR application to retrain upper limb movements and cognitive functions in patients with stroke. The exercise foresees identifying, reaching, and grabbing grocery items on supermarket shelves and paying for them. Currently, we are conducting a study assessing the user experience of patients with sub-acute and chronic stroke undergoing rehabilitation with the VSS over a period of 4 weeks, 3 times a week. Up to now, 9 patients have experienced the supermarket and have answered questionnaires about perceived ease of use, involvement, and cyber-sickness after the first rehabilitation session. The VSS was evaluated satisfactorily, and no side effects emerged. Although preliminary, these outcomes are encouraging, and we expect the positive results to be maintained at the end of the rehabilitation period too. Further studies will be needed to investigate better clinical improvements that the VSS may lead to.

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