Virtual reality for stroke rehabilitation

ObReco-2: Two-step validation of a tool to assess memory deficits using 360° videos

Traditional neuropsychological evaluations are usually carried out using psychometric paper and pencil tests. Nevertheless, there is a continuous discussion concerning their efficacy to capture life-like abilities. The introduction of new technologies, such as Virtual Reality (VR) and 360° spherical photos and videos, has improved the ecological validity of the neuropsychological assessment. The possibility of simulating realistic environments and situations allows clinicians to evaluate patients in realistic activities. Moreover, 360° photos and videos seem to provide higher levels of graphical realism and technical user-friendliness compared to standard VR, regardless of their limitations in terms of interactivity. We developed a novel 360° tool, ObReco-2 (Object Recognition version 2), for the assessment of visual memory which simulates a daily situation in a virtual house. More precisely, patients are asked to memorize some objects that need to be moved for a relocation. After this phase, they are asked to recall them after 15 min and later to recognize them in the same environment. Here we present a first study about the usability of ObReco-2, and a second one exploring its clinical efficacy and updated usability data. We focused on Free Recall and Recognition scores, comparing the performances obtained by the participants in the standard and the 360° test. The preliminary results support the use of 360° technology for enhancing the ecological value of standard memory assessment tests.

Optimising rehabilitation and recovery after a stroke

Stroke can cause significant disability and impact quality of life. Multidisciplinary neurorehabilitation that meets individual needs can help to optimise recovery. Rehabilitation is essential for best quality care but should start early, be ongoing and involve effective teamwork. We describe current stroke rehabilitation processes, from the hyperacute setting through to inpatient and community rehabilitation, to long-term care and report on which UK quality care standards are (or are not) being met. We also examine the gap between what stroke rehabilitation is recommended and what is being delivered, and suggest areas for further improvement.

After 55 Years of Neurorehabilitation, What Is the Plan?

Neurological disorders often cause severe long-term disabilities with substantial activity limitations and participation restrictions such as community integration, family functioning, employment, social interaction and participation. Increasing understanding of brain functioning has opened new perspectives for more integrative interventions, boosting the intrinsic central nervous system neuroplastic capabilities in order to achieve efficient behavioral restitution. Neurorehabilitation must take into account the many aspects of the individual through a comprehensive analysis of actual and potential cognitive, behavioral, emotional and physical skills, while increasing awareness and understanding of the new self of the person being dealt with. The exclusive adoption by the rehabilitator of objective functional measures often overlooks the values and goals of the disabled person. Indeed, each individual has their own rhythm, unique life history and personality construct. In this challenging context, it is essential to deepen the assessment through subjective measures, which more adequately reflect the patient’s perspective in order to shape genuinely tailored instead of standardized neurorehabilitation approaches. In this overly complex panorama, where confounding and prognostic factors also strongly influence potential functional recovery, the healthcare community needs to rethink neurorehabilitation formats.

Bilateral Movement-based Computer Games Improve Sensorimotor Functions in Subacute Stroke Survivors

BACKGROUND

Previous studies have reported that movement-based computer gaming is more effective than conventional intervention in enhancing upper limb rehabilitation.

OBJECTIVE

To evaluate whether the use of bilateral movement-based computer games could augment the effects of conventional intervention in improving the upper limb motor function, grip strength and health-related quality of life of subacute stroke survivors.

METHODS

A total of 93 subjects with subacute stroke were randomized into 2 groups receiving one of two 3.5-h interventions for 2 days per week over 8 weeks: (i) "bilateral movement-based computer games + conventional rehabilitation"; and (ii) "video-directed exercise + conventional rehabilitation" (control group).

RESULTS

A total of 83 subjects completed the interventions and follow-up assessments. Compared with video-directed exercise + conventional rehabilitation, bilateral movement-based computer games + conventional rehabilitation produced greater improvements in upper limb motor impairment from midtreatment to follow-up 1 month post-intervention, greater improvements in upper limb function from post-intervention to 1 month follow-up, and earlier improvements in grip strength (paretic) from midintervention to follow-up 1 month post-intervention. Subjects who received bilateral movement-based computer games + conventional rehabilitation also continued to improve in motor function from postintervention to 1 month post-intervention.

CONCLUSION

Bilateral movement-based computer games may serve as an adjuvant therapy to conventional rehabilitation programmes for improving upper limb recovery among stroke survivors.

Involvement of visual signals in kinaesthesia: A virtual reality study

Body movements are invariably accompanied by various proprioceptive, visual, tactile and/or motor signals. It is therefore difficult to completely dissociate these various signals from each other in order to study their specific involvement in the perception of movement (kinaesthesia). Here, we manipulated visual motion signals in a virtual reality display by using a humanoid avatar. The visual signals of movement could therefore be manipulated freely, relative to the participant's actual movement or lack of movement. After an embodiment phase in which the avatar's movements were coupled to the participant's voluntary movements, kinaesthetic illusions were evoked by moving the avatar's right forearm (flexion or extension) while the participant's right arm remained static. The avatar's left forearm was hidden from view. In parallel, somaesthetic signals could be masked by agonist-antagonist co-vibration or be amplified (by agonist vibration only or antagonist vibration only) so that the real impact of visual cues of movement in kinaesthesia could be studied. In a study of 24 participants, masking the somaesthetic signals (which otherwise provide signals indicating that the arm is static) was associated with a greater intensity and shorter latency of the visually evoked illusions. These results confirm the importance of carefully considering somaesthetic signals when assessing the contribution of vision to kinaesthesia. The use of a combination of virtual reality and somaesthetic signal manipulation might be of clinical value.

Virtual reality exercises at home for post COVID-19 condition: a feasibility study

BACKGROUND

Between 30-76% of COVID-19 patients have persistent physical and mental symptoms, sometimes up to 9 months after acute COVID-19. Current rehabilitation is mostly focused on the physical symptoms, while experts have agreed on the need for a biopsychosocial approach. A novel approach such as Virtual Reality (VR) rehabilitation at home might benefit patients and therapists, especially considering the expected rush of patients with post-COVID-19-condition needing rehabilitation.

OBJECTIVE

To investigate the feasibility of self-administered VR exercises at home for post COVID-19-condition.

METHODS

This is a single-arm feasibility study in an outpatient care setting. Patients who needed physiotherapy because of post COVID-19 condition were included as determined by the treating physiotherapist. Participants performed VR physical exercises at home for a period of 6 weeks and were allowed to perform VR mental exercise apps available at the VR platform to reduce stress and anxiety and promote cognitive functioning. Main outcomes were related to feasibility, i.e. duration and frequency of VR use, safety i.e. adverse events, patient satisfaction, and reasons to withdraw. Physical performance, daily activities, cognitive functioning, anxiety and depression, and quality of life were measured before and after.

RESULTS

Forty-eight patients were included. One patient did not start VR and seven patients (15%) withdrew, mostly due to dizziness. Almost 70% of participants reported any adverse event during VR exercising. However, only 25% recalled these events at the end of the intervention period. The majority of patients described VR as having a positive influence on their recovery and the global satisfaction score was 67%. Average VR use was 30 minutes per session 3-4 times a week for 3-6 weeks. Overall use of VR applications was almost equally distributed over the three sets of VR exercises (physical, relaxing, cognitive). However, use frequency of physical exercises seemed to decrease over time, whereas use of cognitive and relaxation exercises remained stable. Physical performance and quality of life outcomes were significantly improved after six weeks.

CONCLUSIONS

VR physical exercises at home is feasible and safe with good acceptance in a significant percentage of patients with post COVID-19 condition.

CLINICALTRIAL

ClinicalTrials.gov NCT04505761.

Implications of Ezetimibe in Combination with Low- to Moderate-Intensity Atorvastatin Adjuvant Aspirin Therapy for Cerebrovascular Disease

Objective

To analyze the significance of ezetimibe in combination with low- to moderate-intensity atorvastatin adjuvant aspirin therapy for cerebrovascular disease.

Methods

110 patients with cerebrovascular disease treated in our hospital from June 2020 to June 2021 were selected and divided into 55 patients in the control group and 55 patients in the study group according to the lottery method. After a comprehensive examination, patients in the two groups should be given aspirin for treatment; the control group was treated with conventional dose of atorvastatin on top of the above, and the study group was given ezetimibe and medium-low-dose atorvastatin on top of aspirin treatment, activities of daily living (ADL) score, carotid artery intima-media thickness, lipid level, coagulation level, clinical effect, and adverse rate of the two groups which were tested and compared.

Results

After treatment, ADL score, high-density leptin cholesterol (HDL-C), and ATIII levels increased, while carotid artery media thickness, triglyceride (TG), total cholesterol (TC), low-density leptin cholesterol (LDL-C), DD, PC, and hs-CRP levels decreased (P < 0.05). After treatment, ADL score, HDL-C, and ATIII levels were higher in the study group. The levels of carotid media thickness, TG, TC, LDL-C, DD, PC, and hs-CRP were significantly lower (P < 0.05). The clinical effect of the study group was outstanding (P < 0.05). The defect rate of the study group was lower than that of the control group, but there was no difference (P < 0.05).

Conclusion

Ezetimibe combined with medium- and low-intensity atorvastatin with aspirin in the treatment of cerebrovascular diseases can effectively improve the coagulation function of patients, reduce the level of inflammatory factors in patients, and improve the level of blood lipids in patients, with high safety and worthy of clinical application.

Active Virtual Reality for Chronic Primary Pain: Mixed Methods Randomized Pilot Study

Background

The modern management of chronic pain is largely focused on improving functional capacity (often despite ongoing pain) by using graded activation and exposure paradigms. However, many people with chronic pain find functional activation programs aversive, and dropout rates are high. Modern technologies such as virtual reality (VR) could provide a more enjoyable and less threatening way for people with chronic pain to engage in physical activity. Although VR has been successfully used for pain relief in acute and chronic pain settings, as well as to facilitate rehabilitation in conditions such as stroke and cerebral palsy, it is not known whether VR can also be used to improve functional outcomes in people with chronic pain.

Objective

This study aimed to assess the feasibility of conducting an adequately powered randomized controlled trial (RCT) to test the efficacy of VR in a chronic pain treatment center and assess the acceptability of an active VR treatment program for patients in this setting.

Methods

For this mixed methods pilot study, which was designed to test the feasibility and acceptability of the proposed study methods, 29 people seeking treatment for chronic pain were randomized to an active VR intervention or physiotherapy treatment as usual (TAU). The TAU group completed a 6-week waitlist before receiving standard treatment to act as a no-treatment control group. The VR intervention comprised twice-weekly immersive and embodied VR sessions using commercially available gaming software, which was selected to encourage movement. A total of 7 VR participants completed semistructured interviews to assess their perception of the intervention.

Results

Of the 99 patients referred to physiotherapy, 53 (54%) were eligible, 29 (29%) enrolled, and 17 (17%) completed the trial, indicating that running an adequately powered RCT in this setting would not be feasible. Despite this, those in the VR group showed greater improvements in activity levels, pain intensity, and pain interference and reported greater treatment satisfaction and perceived improvement than both the waitlist and TAU groups. Relative effect sizes were larger when VR was compared with the waitlist (range small to very large) and smaller when VR was compared with TAU (range none to medium). The qualitative analysis produced the following three themes: VR is an enjoyable alternative to traditional physiotherapy, VR has functional and psychological benefits despite continued pain, and a well-designed VR setup is important.

Conclusions

The active VR intervention in this study was highly acceptable to participants, produced favorable effects when compared with the waitlist, and showed similar outcomes as those of TAU. These findings suggest that a confirmatory RCT is warranted; however, substantial barriers to recruitment indicate that incentivizing participation and using a different treatment setting or running a multicenter trial are needed.

The Impact of Cognitive Function on Virtual Reality Intervention for Upper Extremity Rehabilitation of Patients With Subacute Stroke: Prospective Randomized Controlled Trial With 6-Month Follow-up

Background

Stroke is among the leading causes of long-term disability worldwide. Motor impairments after stroke not only impact the individuals quality of life but also lay substantial burdens on the society. Motor planning is a key component of cognitive function that impacts motor control. Hand movements such as grasping or reaching to grasp require the application of correct force and the coordination of multiple limb segments. Successful completion of hand motor task requires a certain degree of cognitive function to anticipate the requirement of the task. Cognitive function may thus be a confounding factor to rehabilitation outcomes.

Objective

This study aims to explore the impact of cognitive function on functional outcomes in people with subacute stroke after VR intervention.

Methods

Patients with stroke were first stratified into cognitively normal (CN) and cognitively impaired (CI), followed by allocation to the VR or control group (CG). Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Barthel Index (BI), and Instrumental Activities of Daily Living (IADL) were recorded at baseline, 3 weeks after the intervention, and 3 and 6 months after the intervention. The between-group and within-group differences were assessed by repeated-measures analysis of variance (ANOVA).

Results

The between-group comparison indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) scores improved significantly in both groups after the intervention. Repeated-measures ANOVA indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) were significantly different in each subgroup after the intervention. For BI score, the ANOVA results showed obvious interaction effects (treatment × time × cognitive effect, P=.04).

Conclusions

VR intervention was as effective as traditional conventional therapy in improving upper limb function regardless of the cognitive functional level. Patients with stroke with impaired cognitive function may gain more improvement in upper limb function and independency in performing activities of daily living after a VR-based intervention.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-IOC-15006064; https://tinyurl.com/4c9vkrrn

Virtual reality for the observation of oncology models (VROOM): immersive analytics for oncology patient cohorts

The significant advancement of inexpensive and portable virtual reality (VR) and augmented reality devices has re-energised the research in the immersive analytics field. The immersive environment is different from a traditional 2D display used to analyse 3D data as it provides a unified environment that supports immersion in a 3D scene, gestural interaction, haptic feedback and spatial audio. Genomic data analysis has been used in oncology to understand better the relationship between genetic profile, cancer type, and treatment option. This paper proposes a novel immersive analytics tool for cancer patient cohorts in a virtual reality environment, virtual reality to observe oncology data models. We utilise immersive technologies to analyse the gene expression and clinical data of a cohort of cancer patients. Various machine learning algorithms and visualisation methods have also been deployed in VR to enhance the data interrogation process. This is supported with established 2D visual analytics and graphical methods in bioinformatics, such as scatter plots, descriptive statistical information, linear regression, box plot and heatmap into our visualisation. Our approach allows the clinician to interrogate the information that is familiar and meaningful to them while providing them immersive analytics capabilities to make new discoveries toward personalised medicine.

Virtual Reality combined with Robotic facilitated movements for pain management and sensory stimulation of the upper limb following a Brachial Plexus injury: A case study

Brachial Plexus injuries are complex in nature caused in large by high impact traffic accidents which can lead to additional complications such as Complex Regional Pain Syndrome and even lead to amputation or the need for further surgical intervention. Treatment options to help repair the brachial plexus initially involve surgical intervention and post-surgery rehabilitation with medication to help with ongoing pain. Pain treatments used for these types of injuries are limited and differ in effectiveness. Paradigms utilising multimodal systems such as the one described in this paper based on virtual reality and robotics could yield results that are non-invasive and provide better rehabilitation outcomes for the sufferers. In this paper we present a single case study exploring whether Virtual Reality plus Haptic feedback have any practical potential for reducing upper limb pain and improving function in patients with brachial plexus injuries. The case study is presented with long standing complex combination of phantom limb and neuropathic pain. A decrease in perceived levels of pain was reported which amounts to a 50% reduction in pain from baseline and an improved range of motion. An examination of the sensory phantom map on the stump seems to indicate an early establishment of the thumb representation on the stump close to the area being stimulated with potential implications for prosthesis use.

Highlighting hybridization: a case report of virtual reality-augmented interventions to improve chronic post-stroke recovery

RATIONALE

Cerebrovascular accident, or stroke, is a leading cause of serious long-term disability, and incidence is expected to continue rising in the coming years. Stroke-related disability can manifest as motor, sensory, or cognitive impairment, and although current therapies can improve these impairments, many stroke patients are still left with reduced abilities and struggle to maintain independence in their daily lives. Virtual reality (VR) has been proposed as a novel therapeutic tool to treat stroke-related disability, particularly in conjunction with traditional post-stroke therapies.

PATIENT CONCERNS

Here, we report 1 case of a 75-year-old male with ongoing right upper extremity impairment.

DIAGNOSIS

The patient was previously diagnosed with an ischemic stroke.

INTERVENTIONS

Seven years post-stroke, during which he did not receive any therapies, and on the recommendation of his neurologist, the patient sought VR therapy as an innovative treatment strategy. His clinicians employed a combination of traditional exercise and VR therapy to improve his strength and mobility.

OUTCOMES

The combination of traditional and VR therapy was able to provide meaningful improvement to his daily quality of life, even years after the stroke.

CONCLUSIONS

These results suggest that combination therapy with VR is a viable tool for treating post-stroke impairment, even several years on from the cerebrovascular accident.

Virtual Feedback for Arm Motor Function Rehabilitation after Stroke: A Randomized Controlled Trial

A single-blind randomized controlled trial was conducted to compare whether the continuous visualization of a virtual teacher, during virtual reality rehabilitation, is more effective than the same treatment provided without a virtual teacher visualization, for the recovery of arm motor function after stroke. Teacher and no-teacher groups received the same amount of virtual reality therapy (i.e., 1 h/d, 5 dd/w, 4 ww) and an additional hour of conventional therapy. In the teacher group, specific feedback (“virtual-teacher”) showing the correct kinematic to be emulated by the patient was always displayed online during exercises. In the no-teacher group patients performed the same exercises, without the virtual-teacher assistance. The primary outcome measure was Fugl-Meyer Upper Extremity after treatment. 124 patients were enrolled and randomized, 62 per group. No differences were observed between the groups, but the same number of patients (χ² = 0.29, p = 0.59) responded to experimental and control interventions in each group. The results confirm that the manipulation of a single instant feedback does not provide clinical advantages over multimodal feedback for arm rehabilitation after stroke, but combining 40 h conventional therapy and virtual reality provides large effect of intervention (i.e., Cohen’s d 1.14 and 0.92 for the two groups, respectively).

Effectiveness of Using Virtual Reality-Supported Exercise Therapy for Upper Extremity Motor Rehabilitation in Patients With Stroke: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

In recent years, efforts have been made to implement virtual reality (VR) to support the delivery of poststroke upper extremity motor rehabilitation exercises. Therefore, it is important to review and analyze the existing research evidence of its effectiveness.

Objective

Through a systematic review and meta-analysis of randomized controlled trials, this study examined the effectiveness of using VR-supported exercise therapy for upper extremity motor rehabilitation in patients with stroke.

Methods

This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The CINAHL Plus, MEDLINE, Web of Science, Embase, and Cochrane Library databases were searched on December 31, 2021. Changes in outcomes related to impairments in upper extremity functions and structures, activity limitations, and participation restrictions in life situations from baseline to after intervention, after intervention to follow-up assessment, and baseline to follow-up assessment were examined. Standardized mean differences (SMDs) were calculated using a random-effects model. Subgroup analyses were performed to determine whether the differences in treatment outcomes depended on age, stroke recovery stage, VR program type, therapy delivery format, similarities in intervention duration between study groups, intervention duration in VR groups, and trial length.

Results

A total of 42 publications representing 43 trials (aggregated sample size=1893) were analyzed. Compared with the control groups that used either conventional therapy or no therapy, the intervention groups that used VR to support exercise therapy showed significant improvements in upper extremity motor function (Fugl-Meyer Assessment-Upper Extremity; SMD 0.45, 95% CI 0.21-0.68; P<.001), range of motion (goniometer; SMD 1.01, 95% CI 0.50-1.52; P<.001), muscle strength (Manual Muscle Testing; SMD 0.79, 95% CI 0.28-1.30; P=.002), and independence in day-to-day activities (Functional Independence Measure; SMD 0.23, 95% CI 0.06-0.40; P=.01, and modified Rankin Scale; SMD 0.57, 95% CI 0.01-1.12; P=.046). Significant subgroup differences were observed in hand dexterity (Box and Block Test), spasticity (Ashworth Scale or modified Ashworth Scale), arm and hand motor ability (Wolf Motor Function Test and Manual Function Test), hand motor ability (Jebsen Hand Function Test), and quality of life (Stroke Impact Scale). There was no evidence that the benefits of VR-supported exercise therapy were maintained after the intervention ended.

Conclusions

VR-supported upper extremity exercise therapy can be effective in improving motor rehabilitation results. Our review showed that of the 12 rehabilitation outcomes examined during the course of VR-based therapy, significant improvements were detected in 2 (upper extremity motor function and range of motion), and both significant and nonsignificant improvements were observed in another 2 (muscle strength and independence in day-to-day activities), depending on the measurement tools or methods used.

Trial Registration

PROSPERO CRD42021256826; https://tinyurl.com/2uarftbh

Virtual Reality in the Rehabilitation of Patients with Injuries and Diseases of Upper Extremities

Upper-extremity injuries and diseases rarely have life-threatening consequences, but failure to manage them properly can result in severe dysfunction. This article presents the current state of using virtual reality to support the rehabilitation process of patients with injuries and diseases of the upper extremities and points out their effects on upper-extremity functions. A scoping review was conducted to provide a comprehensive overview of the field of virtual reality for upper-extremity rehabilitation. PubMed, Web of Science, and the Cochrane Library were searched by two independent researchers between April and May 2021 to identify relevant publications and were examined according to inclusion and exclusion criteria. As a result of the literature review, 11 studies of various target groups were identified. Virtual-reality technologies were categorized into multisensory high-end systems and game-based systems. With respect to functional recovery, technologies based on virtual reality were not inferior to traditional rehabilitation. In addition, the users were highly motivated and satisfied. The results emphasize the need for stronger evidence-based virtual-reality technologies for rehabilitation of injuries and diseases of upper extremities.

Effect of virtual reality technology as intervention for people with kinesiophobia: A meta-analysis of randomised controlled trials

AIMS AND OBJECTIVE

To explore the effectiveness of Virtual Reality Technology in reducing kinesiophobia in people.

BACKGROUND

Kinesiophobia is an important psychosocial factor affecting the pain experience and has a significant negative impact on rehabilitation. Virtual reality technology has been widely used in the treatment of phobias, mental disorders and anxiety disorders. However, the effect of virtual reality technology on people with kinesiophobia has been reported with inconsistent results.

DESIGN

A meta-analysis of randomised controlled trials.

METHODS

This study systematically searched PubMed, Web of Science, PsycINFO, CINAHL, Embase, Cochrane Library, Medline, Scopus and four Chinese databases. The standardised mean difference (SMD) was calculated using random-effects models, and the Cochrane Collaboration's tool was used to assess the risk of bias in each study. The PRISMA 2020 checklist provided by the EQUATOR network was used.

RESULTS

Eleven randomised controlled trials involving a total of 488 subjects were included. Meta-analysis showed the effect sizes of virtual reality intervention on kinesiophobia (SMD = -0.53, 95% CI [-0.90, -0.17], p = .004). Virtual reality intervention was more effective in reducing kinesiophobia in people with chronic low back pain (SMD = -1.00, 95% CI [-1.71, -0.29], p = .006). Compared with fully immersive virtual reality (SMD = -0.29, 95% CI [-0.62, 0.05], p = 0.09), non-immersive virtual reality was more effective in reducing kinesiophobia (SMD = -0.66, 95% CI [-1.24, -0.09], p = 0.02). Compared with virtual reality intervention alone (SMD = -0.35, 95% CI [-1.40, 0.71], p = 0.52), virtual reality combined with exercise was more effective in reducing kinesiophobia (SMD = -0.59, 95% CI [-0.95, -0.22], p = 0.002).

CONCLUSIONS

Virtual reality technology has the potential to reduce the degree of kinesiophobia in people. In addition, virtual reality technology was more effective in people with chronic low back pain; non-immersive virtual reality was more effective in reducing kinesiophobia; and virtual reality technology combined with exercise was more effective in reducing kinesiophobia than virtual reality intervention alone. Clinical nursing staff should be encouraged to use virtual reality to speed up patient recovery. However, to achieve immersion and apply this technology to different diseases, more studies are required to provide clearer suggestions.

RELEVANCE TO CLINICAL PRACTICE

This study suggests that healthcare staff should pay attention to kinesiophobia, and early identification and intervention of kinesiophobia can help patients recover their health and improve the quality of nursing.

An sEMG-Controlled Forearm Bracelet for Assessing and Training Manual Dexterity in Rehabilitation: A Systematic Review

Background: The ability to perform activities of daily living (ADL) is essential to preserving functional independence and quality of life. In recent years, rehabilitation strategies based on new technologies, such as MYO Armband^®, have been implemented to improve dexterity in people with upper limb impairment. Over the last few years, many studies have been published focusing on the accuracy of the MYO Armband^® to capture electromyographic and inertial data, as well as the clinical effects of using it as a rehabilitation tool in people with loss of upper limb function. Nevertheless, to our knowledge, there has been no systematic review of this subject. Methods: A systematically comprehensive literature search was conducted in order to identify original studies that answered the PICO question (patient/population, intervention, comparison, and outcome): What is the accuracy level and the clinical effects of the MYO Armband^® in people with motor impairment of the upper limb compared with other assessment techniques or interventions or no intervention whatsoever? The following data sources were used: Pubmed, Scopus, Web of Science, ScienceDirect, Physiotherapy Evidence Database, and the Cochrane Library. After identifying the eligible articles, a cross-search of their references was also completed for additional studies. The following data were extracted from the papers: study design, disease or condition, intervention, sample, dosage, outcome measures or data collection procedure and data analysis and results. The authors independently collected these data following the CONSORT 2010 statement when possible, and eventually reached a consensus on the extracted data, resolving disagreements through discussion. To assess the methodological quality of papers included, the tool for the critical appraisal of epidemiological cross-sectional studies was used, since only case series studies were identified after the search. Additionally, the articles were classified according to the levels of evidence and grades of recommendation for diagnosis studies established by the Oxford Center for Evidence-Based Medicine. Also, The Cochrane Handbook for Systematic Reviews of Interventions was used by two independent reviewers to assess risk of bias, assessing the six different domains. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed to carry out this review. Results: 10 articles with a total 180 participants were included in the review. The characteristics of included studies, sample and intervention characteristics, outcome measures, the accuracy of the system and effects of the interventions and the assessment of methodological quality of the studies and risk of bias are shown. Conclusions: Therapy with the MYO Armband^® has shown clinical changes in range of motion, dexterity, performance, functionality and satisfaction. It has also proven to be an accurate system to capture signals from the forearm muscles in people with motor impairment of the upper limb. However, further research should be conducted using bigger samples, well-defined protocols, comparing with control groups or comparing with other assessment or therapeutic tools, since the studies published so far present a high risk of bias and low level of evidence and grade of recommendation.

Virtual reality for the assessment and rehabilitation of neglect: where are we now? A 6-year review update

Unilateral spatial neglect (USN) is a frequent repercussion of a cerebrovascular accident, typically a stroke. USN patients fail to orient their attention to the contralesional side to detect auditory, visual, and somatosensory stimuli, as well as to collect and purposely use this information. Traditional methods for USN assessment and rehabilitation include paper-and-pencil procedures, which address cognitive functions as isolated from other aspects of patients' functioning within a real-life context. This might compromise the ecological validity of these procedures and limit their generalizability; moreover, USN evaluation and treatment currently lacks a gold standard. The field of technology has provided several promising tools that have been integrated within the clinical practice; over the years, a "first wave" has promoted computerized methods, which cannot provide an ecological and realistic environment and tasks. Thus, a "second wave" has fostered the implementation of virtual reality (VR) devices that, with different degrees of immersiveness, induce a sense of presence and allow patients to actively interact within the life-like setting. The present paper provides an updated, comprehensive picture of VR devices in the assessment and rehabilitation of USN, building on the review of Pedroli et al. (2015). The present paper analyzes the methodological and technological aspects of the studies selected, considering the issue of usability and ecological validity of virtual environments and tasks. Despite the technological advancement, the studies in this field lack methodological rigor as well as a proper evaluation of VR usability and should improve the ecological validity of VR-based assessment and rehabilitation of USN.

Physiotherapy Programmes Aided by VR Solutions Applied to the Seniors Affected by Functional Capacity Impairment: Randomised Controlled Trial

Modern technologies are presently harnessed in response to a complex challenge of providing physiotherapeutic management in older adults. Fully immersive virtual reality (VR) solutions are acknowledged to viably enhance the overall effectiveness of traditional physiotherapeutic methods. A total of 60 community-dwelling older adults (over 75 years of age) were recruited for the study protocol. They were subsequently randomly split into four equally sized study groups (VR, CVR, OCULUS, and the classic programme group (OTAGO), and the physiotherapy sessions were pursued in the subjects’ homes for 3 weeks, 3 times a week, for 30 min in each group. At the first measurement point, respective study groups differed significantly in functional performance, as expressed in gait (POMA G) and individual static balance. The post hoc analysis indicated significantly higher scores in POMA G for the classic programme group vs. the results of the VR and CVR groups. On the other hand, the OCULUS group held significantly higher scores in individual balance and TUG, as compared to the other groups (p < 0.001). Making use of a virtual reality (VR) environment in the physiotherapeutic management of community-dwelling older adults appreciably enhanced individual functional performance, especially in terms of static balance. Physiotherapy management aided by VR technology solutions offers a viable alternative to traditional physiotherapeutic regimens (e.g., OTAGO programme) in enhancing individual functional performance. The innovatively self-designed VIRTUAL REALITY COMPREHENSIVE REHABILITATION ROOMS (VRCRR) solution may help out in pursuing a complex physiotherapy programme on an individual basis within one’s own home environment.

The Application of Artificial Neural Network Combined with Virtual Reality Technology in Environment Art Design

Virtual reality is a computer technology that produces a simulated environment. It is completely immersive and gives users the viewpoint that they are somewhere else. In recent times, it has become a highly interactive and visualization tool that has gained interest among educators and scholars. Art learning is a teaching-learning approach that is dependent on learning "through the arts" and "with the arts;" it can be a procedure in which art develops the medium of teaching-learning and an important model in some subjects of the curriculum. In this work, we develop a grey wolf optimization with the residual network form of virtual reality application for environmental art learning (GWORN-EAL) technique. It aims to provide metacognitive actions to improve environmental art learning for young children or adults. The GWORN-EAL technique is mainly based on the stimulation of particular features of the target painting over a default image. The color palette of the recognized image of the Fauve painter was mapped to the target image using the Fauve vision of the painter and represented by vivid colors. For optimal hyperparameter tuning of the ResNet model, the GWO algorithm is employed. The experimental results indicated that the GWORN-EAL technique has accomplished effectual outcomes in several aspects. A brief experimental study highlighted the improvement of the GWORN-EAL technique compared to existing models.

Are Extended Reality Interventions Effective in Helping Autistic Children to Enhance Their Social Skills? A Systematic Review

Autistic children’s social skills do not always align with those of their neurotypical peers and research suggests that this can negatively impact quality of life. This review aimed to assess the effectiveness of extended reality (XR) interventions in helping autistic children to enhance their social skills. Five electronic databases were systematically searched and seventeen studies were identified. The majority targeted social-emotional reciprocity and were of relatively low quality. There was insufficient evidence to determine whether effects were generalisable, sustained or important to autistic people. Research in this field is in its infancy and evidence of effectiveness should be viewed with caution. Future studies should aim for high-quality, theory-driven research, and involve autistic people to ensure meaningful outcomes.

PROSPERO ID: CRD42021229442

Virtual Reality and Lower Limb Rehabilitation: Effects on Motor and Cognitive Outcome-A Crossover Pilot Study

The effectiveness of virtual reality (VR) in the motor and cognitive rehabilitation of patients with severe acquired brain injury (sABI) is unclear. This randomized, controlled, crossover, single-blinded, pilot study investigates the cognitive and motor effects of lower limb robotic therapy with and without VR visual feedback in a group of patients with ABI. A total of 23 patients with ABI were randomized into two groups: one group (VR-NVR) underwent a 2-week rehabilitation for the lower limbs training with a robotic device (Omego^®) with VR feedback, followed by 2 weeks without VR; the other group (NVR-VR) performed the protocol in the opposite order. Patients were evaluated at baseline, after two and four weeks of treatment using the Level of Cognitive Functioning scale (LCF), Disability Rating Scale (DRS), and Motricity Index for Lower Limb (MI-LL) in the most affected limb. At the end of the intervention, both groups significantly improved in all the outcomes. A significant difference was found between VR treatment versus non-VR treatment for LCF (p = 0.024) and for DRS (p = 0.043) after the second week, while no significant differences were found in the group NVR-VR at T1. Our study indicates how the combination of robotic treatment with VR is effective in enhancing the recovery of cognitive function in patients with ABI, also improving disability and muscular function. Further, VR seems to enhance the early recovery process of motor and cognitive functions.

Robotic Table and Serious Games for Integrative Rehabilitation in the Early Poststroke Phase: Two Case Reports

BACKGROUND

BrightArm Compact is a new rehabilitation system for the upper extremities. It provides bimanual training with gradated gravity loading and mediates interactions with cognitively challenging serious games.

OBJECTIVE

The aim of this study is to design and test a robotic rehabilitation table-based virtual rehabilitation system for functional impact of the integrative training in the early poststroke phase.

METHODS

A new robotic rehabilitation table, controllers, and adaptive games were developed. The 2 participants underwent 12 experimental sessions in addition to the standard of care. Standardized measures of upper extremity function (primary outcome), depression, and cognition were administered before and after the intervention. Nonstandardized measures included game variables and subjective evaluations.

RESULTS

The 2 case study participants attained high total arm repetitions per session (504 and 957) and achieved high grasp and finger-extension counts. Training intensity contributed to marked improvements in affected shoulder strength (225% and 100% increase), grasp strength (27% and 16% increase), and pinch strength (31% and 15% increase). The shoulder flexion range increased by 17% and 18% and elbow supination range by 75% and 58%. Improvements in motor function were at or above minimal clinically important difference for the Fugl-Meyer Assessment (11 and 10 points), Chedoke Arm and Hand Activity Inventory (11 and 14 points), and Upper Extremity Functional Index (19 and 23 points). Cognitive and emotive outcomes were mixed. Subjective rating by participants and training therapists were positive (average 4, SD 0.22, on a 5-point Likert scale).

CONCLUSIONS

The design of the robotic rehabilitation table was tested on 2 participants in the early poststroke phase, and results are encouraging for upper extremity functional gains and technology acceptance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04252170; https://clinicaltrials.gov/ct2/show/NCT04252170.

Considerations for Voice and Communication Training Software for Transgender and Nonbinary People

Transgender and gender diverse people often experience voice-gender incongruence, which is inversely correlated with health and quality of life. Such incongruence could be reduced with voice and communication training, but expert-administered training is often inaccessible while self-guided training is difficult and potentially risky. Training could alternatively be provided through software (eg, smartphone apps), but such software is at an early stage. This qualitatively driven mixed-methods study thus includes surveys and interviews with 21 transfeminine, transmasculine and nonbinary people to identify general views of voice and communication training software as well as most desirable features of such software. Participants were positive about the general idea and described ways to effectively implement four critical features: feedback, accountability, automated goal setting, and training characteristics other than pitch. They also discussed optional or undesirable features. These findings may inform development of voice and communication training software, thus improving health and quality of life for gender minorities.

Validity and Reliability of Kinect v2 for Quantifying Upper Body Kinematics during Seated Reaching

Kinematic analysis of the upper limbs is a good way to assess and monitor recovery in individuals with stroke, but it remains little used in clinical routine due to its low feasibility. The aim of this study is to assess the validity and reliability of the Kinect v2 for the analysis of upper limb reaching kinematics. Twenty-six healthy participants performed seated hand-reaching tasks while holding a dumbbell to induce behaviour similar to that of stroke survivors. With the Kinect v2 and with the VICON, 3D upper limb and trunk motions were simultaneously recorded. The Kinect assesses trunk compensations, hand range of motion, movement time and mean velocity with a moderate to excellent reliability. In contrast, elbow and shoulder range of motion, time to peak velocity and path length ratio have a poor to moderate reliability. Finally, instantaneous hand and elbow tracking are not precise enough to reliably assess the number of velocity peaks and the peak hand velocity. Thanks to its ease of use and markerless properties, the Kinect can be used in clinical routine for semi-automated quantitative diagnostics guiding individualised rehabilitation of the upper limb. However, engineers and therapists must bear in mind the tracking limitations of the Kinect.

Occupational therapy for cognitive impairment in stroke patients

BACKGROUND

Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. Occupational therapists use a range of interventions when working with people who have cognitive impairment poststroke. This is an update of a Cochrane Review published in 2010.

OBJECTIVES

To assess the impact of occupational therapy on activities of daily living (ADL), both basic and instrumental, global cognitive function, and specific cognitive abilities in people who have cognitive impairment following a stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases (all last searched September 2020), trial registries, and reference lists.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that evaluated an intervention for adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or considered within the scope of occupational therapy practice as defined in the review. We excluded studies focusing on apraxia or perceptual impairments or virtual reality interventions as these are covered by other Cochrane Reviews. The primary outcome was basic activities of daily living (BADL) such as dressing, feeding, and bathing. Secondary outcomes were instrumental ADL (IADL) (e.g. shopping and meal preparation), community integration and participation, global cognitive function and specific cognitive abilities (including attention, memory, executive function, or a combination of these), and subdomains of these abilities. We included both observed and self-reported outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies that met the inclusion criteria, extracted data, and assessed the certainty of the evidence. A third review author moderated disagreements if consensus was not reached. We contacted trial authors for additional information and data, where available. We assessed the certainty of key outcomes using GRADE.  MAIN RESULTS: We included 24 trials from 11 countries involving 1142 (analysed) participants (two weeks to eight years since stroke onset). This update includes 23 new trials in addition to the one study included in the previous version. Most were parallel randomised controlled trials except for one cross-over trial and one with a two-by-two factorial design. Most studies had sample sizes under 50 participants. Twenty studies involved a remediation approach to cognitive rehabilitation, particularly using computer-based interventions. The other four involved a compensatory and adaptive approach. The length of interventions ranged from 10 days to 18 weeks, with a mean total length of 19 hours. Control groups mostly received usual rehabilitation or occupational therapy care, with a few receiving an attention control that was comparable to usual care; two had no intervention (i.e. a waiting list). Apart from high risk of performance bias for all but one of the studies, the risk of bias for other aspects was mostly low or unclear.  For the primary outcome of BADL, meta-analysis found a small effect on completion of the intervention with a mean difference (MD) of 2.26 on the Functional Independence Measure (FIM) (95% confidence interval (CI) 0.17 to 4.22; P = 0.03, I2 = 0%; 6 studies, 336 participants; low-certainty evidence). Therefore, on average, BADL improved by 2.26 points on the FIM that ranges from 18 (total assist) to 126 (complete independence). On follow-up, there was insufficient evidence of an effect at three months (MD 10.00, 95% CI -0.54 to 20.55; P = 0.06, I2 = 53%; 2 studies, 73 participants; low-certainty evidence), but evidence of an effect at six months (MD 11.38, 95% CI 1.62 to 21.14, I2 = 12%; 2 studies, 73 participants; low-certainty evidence). These differences are below 22 points which is the established minimal clinically important difference (MCID) for the FIM for people with stroke. For IADL, the evidence is very uncertain about an effect (standardised mean difference (SMD) 0.94, 95% CI 0.41 to 1.47; P = 0.0005, I2 = 98%; 2 studies, 88 participants). For community integration, we found insufficient evidence of an effect (SMD 0.09, 95% CI -0.35 to 0.54; P = 0.68, I2 = 0%; 2 studies, 78 participants). There was an improvement of clinical importance in global cognitive functional performance after the intervention (SMD 0.35, 95% CI 0.16 to 0.54; P = 0.0004, I2 = 0%; 9 studies, 432 participants; low-certainty evidence), equating to 1.63 points on the Montreal Cognitive Assessment (MoCA) (95% CI 0.75 to 2.52), which exceeds the anchor-based MCID of the MoCA for stroke rehabilitation patients of 1.22. We found some effect for attention overall (SMD -0.31, 95% CI -0.47 to -0.15; P = 0.0002, I2 = 20%; 13 studies, 620 participants; low-certainty evidence), equating to a difference of 17.31 seconds (95% CI 8.38 to 26.24), and for executive functional performance overall (SMD 0.49, 95% CI 0.31 to 0.66; P < 0.00001, I2 = 74%; 11 studies, 550 participants; very low-certainty evidence), equating to 1.41 points on the Frontal Assessment Battery (range: 0-18). Of the cognitive subdomains, we found evidence of effect of possible clinical importance, immediately after intervention, for sustained visual attention (moderate certainty) equating to 15.63 seconds, for working memory (low certainty) equating to 59.9 seconds, and thinking flexibly (low certainty), compared to control.

AUTHORS' CONCLUSIONS

The effectiveness of occupational therapy for cognitive impairment poststroke remains unclear. Occupational therapy may result in little to no clinical difference in BADL immediately after intervention and at three and six months' follow-up. Occupational therapy may slightly improve global cognitive performance of a clinically important difference immediately after intervention, likely improves sustained visual attention slightly, and may slightly increase working memory and flexible thinking after intervention. There is evidence of low or very low certainty or insufficient evidence for effect on other cognitive domains, IADL, and community integration and participation.  Given the low certainty of much of the evidence in our review, more research is needed to support or refute the effectiveness of occupational therapy for cognitive impairment after stroke. Future trials need improved methodology to address issues including risk of bias and to better report the outcome measures and interventions used.

Virtual Reality Technology in Cognitive Rehabilitation Application: A Bibliometric Analysis (Preprint)

Background

In recent years, with the development of computer science and medical science, virtual reality (VR) technology has become a promising tool for improving cognitive function. Research on VR-based cognitive training has garnered increasing attention.

Objective

This study aimed to investigate the application status, research hot spots, and emerging trends of VR in cognitive rehabilitation over the past 20 years.

Methods

Articles on VR-based cognitive rehabilitation from 2001 to 2021 were retrieved from the Web of Science Core Collection. CiteSpace software was used for the visual analysis of authors and countries or regions, and Scimago Graphica software was used for the geographic visualization of published countries or regions. Keywords were clustered using the gCLUTO software.

Results

A total of 1259 papers were included. In recent years, research on the application of VR in cognitive rehabilitation has been widely conducted, and the annual publication of relevant literature has shown a positive trend. The main research areas include neuroscience and neurology, psychology, computer science, and rehabilitation. The United States ranked first with 328 papers, and Italy ranked second with 140 papers. Giuseppe Riva, an Italian academic, was the most prolific author with 29 publications. The most frequently cited reference was “Using Reality to Characterize Episodic Memory Profiles in Amnestic Mild Cognitive Impairment and Alzheimer’s Disease: Influence of Active and Passive Encoding.” The most common keywords used by researchers include “virtual reality,” “cognition,” “rehabilitation,” “performance,” and “older adult.” The largest source of research funding is from the public sector in the United States.

Conclusions

The bibliometric analysis provided an overview of the application of VR in cognitive rehabilitation. VR-based cognitive rehabilitation can be integrated into multiple disciplines. We conclude that, in the context of the COVID-19 pandemic, the development of VR-based telerehabilitation is crucial, and there are still many problems that need to be addressed, such as the lack of consensus on treatment methods and the existence of safety hazards.

Determining the Optimal Virtual Reality Exergame Approach for Balance Therapy in Persons With Neurological Disorders Using a Rasch Analysis: Longitudinal Observational Study

Background

Virtual reality (VR) exergames have gained popularity in the rehabilitation of persons with neurological disorders as an add-on therapy to increase intensity of training. Intensity is strongly dependent on the motivation of the patient. Motivation can be increased by delivering variation within training and challenging exercises. However, patients are often underchallenged, as exergame difficulty often does not match the patient’s ability. A Rasch analysis can establish hierarchy of exergame items in order to assist the delivery of patient-centered therapy.

Objective

The aim of this study was to apply the Rasch model to create a hierarchical order of existing VR balance exergames and to relate these exergames to the abilities of persons with neurological disorders, in order to deliver challenge and variation.

Methods

A total of 30 persons with stroke and 51 persons with multiple sclerosis (MS) were included in the study. All participants performed a training program, lasting 3 weeks for persons with MS and 4 weeks for persons with stroke, in which they performed VR balance exergames with a movement recognition–based system (MindMotion GO; MindMaze SA). VR exercise scores, Berg Balance Scale scores, and clinical descriptive data were collected. Berg Balance Scale and device scores were analyzed with the Rasch model using a repeated-measures approach to examine whether the distribution of exercise scores fitted the Rasch model. Secondly, a person-item map was created to show the hierarchy of exercise difficulty and person ability.

Results

Participants completed a selection of 56 balance exercises (ie, items), which consisted of a combination of various balance tasks and levels (ie, exercises). Using repeated measures, this resulted in a count of 785 observations. Analysis showed strong evidence for unidimensionality of the data. A total of 47 exercises (ie, items) had a sufficiently good fit to the Rasch model. Six items showed underfit, with outfit mean square values above 1.5. One item showed underfit but was kept in the analysis. Three items had negative point-biserial correlations. The final model consisted of 47 exercises, which were provided for persons with low to moderate balance ability.

Conclusions

The VR exercises sufficiently fitted the Rasch model and resulted in a hierarchical order of VR balance exercises for persons with stroke and MS with low to moderate balance ability. In combination with the Berg Balance Scale, the results can guide clinical decision-making in the selection of patient-focused VR balance exercises.

Trial Registration

ClinicalTrials.gov NCT03993275; https://clinicaltrials.gov/ct2/show/NCT03993275

Effectiveness of action observation therapy based on virtual reality technology in the motor rehabilitation of paretic stroke patients: a randomized clinical trial

BACKGROUND

The rehabilitation of paretic stroke patients uses a wide range of intervention programs to improve the function of impaired upper limb. A new rehabilitative approach, called action observation therapy (AOT) is based on the discovery of mirror neurons and has been used to improve the motor functions of adult stroke patients and children with cerebral palsy. Recently, virtual reality (VR) has provided the potential to increase the frequency and effectiveness of rehabilitation treatment by offering challenging and motivating tasks.  METHODS: The purpose of the present project is to design a randomized controlled six-month follow-up trial (RCT) to evaluate whether action observation (AO) added to standard VR (AO + VR) is effective in improving upper limb function in patients with stroke, compared with a control treatment consisting of observation of naturalistic scenes (CO) without any action content, followed by VR training (CO + VR).

DISCUSSION

AO + VR treatment may provide an addition to the rehabilitative interventions currently available for recovery after stroke and could be utilized within standard sensorimotor training or in individualized tele-rehabilitation.

TRIAL REGISTRATION

The trial has been prospectively registered on ClinicalTrials.gov. NCT05163210 . 17 December 2021.

Efficacy of virtual reality-based interventions for patients with breast cancer symptom and rehabilitation management: a systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of virtual reality (VR)-based intervention on the symptoms and rehabilitation management in patients with breast cancer.

DESIGN

Systematic review and meta-analysis.

STUDY SELECTION

We included all eligible randomised controlled trials and quasi-experimental studies (published in English and Chinese).

PARTICIPANTS

Patients with breast cancer (≥18 years) undergoing cancer treatment.

INTERVENTIONS

Any intervention administered to improve the symptoms and rehabilitation of patients with breast cancer. The control group was given conventional care.

OUTCOMES

All outcomes were as follows: pain, fatigue, anxiety, depressive symptoms, cognitive function, and range of motion of upper limb in patients with breast cancer.

DATA SOURCES

We searched PubMed, Embase, CENTRAL and SinoMed, four electronic databases, covering the database establishment period to January 2022.

REVIEW METHODS

Two reviewers independently extracted content and data consistent with the prespecified framework and assessed risk bias. Random-effects meta-analysis was used to pool data across trials. Meta-analysis was performed using Review Manager V.5.4.

RESULTS

A total of eight studies met the eligibility criteria and were included in this study. The combined effect size showed that VR was positive for improving patients' anxiety(standard mean differenc (SMD)=-2.07, 95% CI= (-3.81 to -0.34), I²=95%) and abduction of upper limbs (MD=15.54, 95% CI= (12.79 to 18.29), I²=0%), but fatigue (SMD=-0.92, 95% CI= (-4.47 to 2.62), I²=99%) was not. Qualitative analysis showed VR improved patients' depressive symptoms, pain and cognitive function.

CONCLUSIONS

VR technology has a good effect on symptoms and rehabilitation management of patients with breast cancer, but the quality of evidence is low, and the sample size is small. To date, there are few intervention studies, therefore, giving precise recommendation or conclusion is difficult. We have a favourable view of this, and more clinical studies are needed in the future to improve the credibility of the results.

A Perspective on Implementation of Technology-Driven Exergames for Adults as Telerehabilitation Services

A major concern of public health authorities is to also encourage adults to be exposed to enriched environments (sensory and cognitive-motor activity) during the pandemic lockdown, as was recently the case worldwide during the COVID-19 outbreak. Games for adults that require physical activity, known as exergames, offer opportunities here. In particular, the output of the gaming industry nowadays offers computer games with extended reality (XR) which combines real and virtual environments and refers to human-machine interactions generated by computers and wearable technologies. For example, playing the game in front of a computer screen while standing or walking on a force plate or treadmill allows the user to react to certain infrastructural changes and obstacles within the virtual environment. Recent developments, optimization, and minimizations in wearable technology have produced wireless headsets and sensors that allow for unrestricted whole-body movement. This makes the virtual experience more immersive and provides the opportunity for greater engagement than traditional exercise. Currently, XR serves as an umbrella term for current immersive technologies as well as future realities that enhance the experience with features that produce new controllable environments. Overall, these technology-enhanced exergames challenge the adult user and modify the experience by increasing sensory stimulation and creating an environment where virtual and real elements interact. As a therapy, exergames can potentially create new environments and visualizations that may be more ecologically valid and thus simulate real activities of daily living that can be trained. Furthermore, by adding telemedicine features to the exergame, progress over time can be closely monitored and feedback provided, offering future opportunities for cognitive-motor assessment. To more optimally serve and challenge adults both physically and cognitively over time in future lockdowns, there is a need to provide long-term remote training and feedback. Particularly related to activities of daily living that create opportunities for effective and lasting rehabilitation for elderly and sufferers from chronic non-communicable diseases (CNDs). The aim of the current review is to envision the remote training and monitoring of physical and cognitive aspects for adults with limited mobility (due to disability, disease, or age), through the implementation of concurrent telehealth and exergame features using XR and wireless sensor technologies.

Effects of Exergaming in Patients with Cardiovascular Disease Compared to Conventional Cardiac Rehabilitation: A Systematic Review and Meta-Analysis

Background: Exercise-based cardiac rehabilitation (CR) programs are used for improving prognosis and quality of life in patients with cardiovascular disease (CVD). Nonetheless, adherence to these programs is low, and exercise-based CR programs based on virtual reality (i.e., exergaming) have been proposed as an alternative to conventional CR programs. However, whether exergaming programs are superior to conventional CR programs in patients with CVD is not known. Objective: This systematic review with meta-analysis was conducted to explore whether exergaming enhances exercise capacity, quality of life, mental health, motivation, and exercise adherence to a greater extent than conventional CR programs in patients with CVD. Method: Electronic searches were carried out in PubMed, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases up to June 2021. Meta-analyses were performed using robust variance estimation with small-sample corrections. The effect sizes were calculated as the mean differences (MD) or standardized mean differences (SMD) as appropriate. The SMD magnitude was classified as trivial (<0.20), small (0.20−0.49), medium (0.50−0.79), or large (≥0.80). Heterogeneity was interpreted based on the I2 statistics as low (25%), moderate (50%), or high (75%). Results: Pooled analyses showed no differences between exergaming and conventional CR programs for enhancing exercise capacity (i.e., distance covered in the six-minute walk test) (MD+ = 14.07 m (95% confidence interval (CI) −38.18 to 66.32 m); p = 0.426) and mental health (SMD+ = 0.17 (95% CI −0.36 to 0.70); p = 0.358). The results showed a small, statistically nonsignificant improvement in quality of life in favor of exergaming (SMD+ = 0.22 (95% CI = −0.37 to 0.81); p = 0.294). Moderate heterogeneity was found for exercise capacity (I2 = 53.7%), while no heterogeneity was found for quality of life (I2 = 3.3%) and mental health (I2 = 0.0%). Conclusions: Exergaming seems not to be superior to conventional CR programs for improving exercise capacity, quality of life, or mental health in patients with CVD.

Feasibility and Efficacy of a Virtual Reality Game-Based Upper Extremity Motor Function Rehabilitation Therapy in Patients with Chronic Stroke: A Pilot Study

BACKGROUND

The objective of the present study was to develop a virtual reality protocol based on activities of daily living and conventional rehabilitation, using Leap Motion Controller to improve motor function in upper extremity rehabilitation in stroke patients. At the same time, the purpose was to explore its efficacy in the recovery of upper extremity motor function in chronic stroke survivors, and to determine feasibility, satisfaction and attendance rate; Methods: A prospective pilot experimental clinical trial was conducted. The outcome measures used were the grip strength, the Action Research Arm Test (ARAT), the Block and Box Test (BBT), the Short Form Health Survey-36 Questionnaire, a satisfaction questionnaire and attendance rate; Results: Our results showed statistically significant changes in the variables grip strength, BBT and ARAT as well as high levels of satisfaction and attendance; Conclusions: This virtual reality platform represents an effective tool in aspects of upper extremity functionality rehabilitation in patients with chronic stroke, demonstrating feasibility and high levels of attendance and satisfaction.

Gamified Neurorehabilitation Strategies for Post-stroke Motor Recovery: Challenges and Advantages

Abstract

Purpose of Review

Stroke is the leading cause of permanent motor disability in the United States (US), but there has been little progress in developing novel, effective strategies for treating post-stroke motor deficits. The past decade has seen the rapid development of many promising, gamified neurorehabilitation technologies; however, clinical adoption remains limited. The purpose of this review is to evaluate the recent literature surrounding the adoption and use of gamification in neurorehabilitation after stroke.

Recent Findings

Gamification of neurorehabilitation protocols is both feasible and effective. Deployment strategies and scalability need to be addressed with more rigor. Relationship between engaged time on task and rehabilitation outcomes should be explored further as it may create benefits beyond repetitive movement.

Summary

As gamification becomes a more common and feasible way of delivering exercise-based therapies, additional benefits of gamification are emerging. In spite of this, questions still exist about scalability and widespread clinical adoption.

Safety, feasibility, acceptability and preliminary effects of the Neurofenix platform for Rehabilitation via HOMe Based gaming exercise for the Upper-limb post Stroke (RHOMBUS): results of a feasibility intervention study

OBJECTIVES

To investigate the safety, feasibility and acceptability of the Neurofenix platform for home-based rehabilitation of the upper limb (UL).

DESIGN

A non-randomised intervention design with a parallel process evaluation.

SETTING

Participants' homes, South-East England.

PARTICIPANTS

Thirty adults (≥18 years), minimum 12-week poststroke, not receiving UL rehabilitation, scoring 9-25 on the Motricity Index (elbow and shoulder), with sufficient cognitive and communicative abilities to participate.

INTERVENTIONS

Participants were trained to use the platform, followed by 1 week of graded game-play exposure and 6-week training, aiming for a minimum 45 min, 5 days/week.

OUTCOMES

Safety was determined by assessing pain and poststroke fatigue at 8 and 12 weeks, and adverse events (AEs). Impairment, activity and participation outcomes were measured. Intervention feasibility was determined by the amount of specialist training and support required to complete the intervention, time and days spent training, and number of UL movements performed. Acceptability was assessed by a satisfaction questionnaire and semistructured interviews.

RESULTS

Participants (14 women; mean (SD) age 60.0 (11.3) years) were a median of 4.9 years poststroke (minimum-maximum: 1-28 years). Twenty-seven participants completed the intervention. The odds of having shoulder pain were lower at 8 weeks (OR 0.45, 95% CI 0.24 to 0.83, p=0.010) and 12 weeks (OR 0.46, 95% CI 0.25 to 0.86, p=0.014) compared with baseline. Fugl-Meyer upper extremity, Motor Activity Log and passive range of movement improved. No other gains were recorded. Poststroke fatigue did not change. Thirty mild and short-term AEs and one serious (unrelated) AE were reported by 19 participants. Participants trained with the platform for a median of 17.4 hours over 7 weeks (minimum-maximum: 0.3-46.9 hours), equating to a median of 149 min per week. The median satisfaction score was 36 out of 40.

CONCLUSION

The Neurofenix platform is a safe, feasible and well accepted way to support UL training for people at least three months poststroke.

TRIAL REGISTRATION NUMBER

ISRCTN60291412.

A Novel Approach to Increase Attention during Mirror Therapy among Stroke Patients: A Video-Based Behavioral Analysis

Stroke is a major cause of disability and an evident rehabilitation strategy is crucial. Mirror therapy (MT) is one of the popular rehabilitation methods that is known to be effective as the patients benefit from the mirror illusion. However, the patient’s attention to the mirror illusion during treatment is unclear. Therefore, the present study assesses the duration and frequency of the mirror gaze, distraction, and preparation of sixteen stroke patients during two MT methods using a behavioral coding software. During the 30 min treatment, the total mirror gaze duration during conventional bilateral MT (BMT) was 564.04 s, while it was 1482.45 s in unilateral MT using a screen (UMT). The total distracted time was 945.61 s in BMT, while it was only 162.03 s in UMT. The total preparatory duration was 290.35 s in BMT and 155.53 s in UMT. The total number of distracted bouts were 136.45 in BMT, while it was 73.38 in UMT. The total number of preparatory bouts were 18.42 in BMT and 9.56 in UMT. The average times of gaze duration per bout were 5.52 s in BMT and 21.81 s in UMT. The average times of distraction per bout were 9.22 s in BMT and 3.00 s in UMT. The total number of mirror gaze bouts and average time of preparation per bout did not present a statistical significance in the comparisons of the two methods. This study assesses two methods of MT using observational coding software to evaluate the duration and frequency of the mirror gaze during treatment. The results suggest that UMT may be an alternative option to provide MT for stroke patients to increase their attention towards the mirror.

Performance of machine learning models in estimation of ground reaction forces during balance exergaming

Background

Balance training exercise games (exergames) are a promising tool for reducing fall risk in elderly. Exergames can be used for in-home guided exercise, which greatly increases availability and facilitates independence. Providing biofeedback on weight-shifting during in-home balance exercise improves exercise efficiency, but suitable equipment for measuring weight-shifting is lacking. Exergames often use kinematic data as input for game control. Being able to useg such data to estimate weight-shifting would be a great advantage. Machine learning (ML) models have been shown to perform well in weight-shifting estimation in other settings. Therefore, the aim of this study was to investigate the performance of ML models in estimation of weight-shifting during exergaming using kinematic data.

Methods

Twelve healthy older adults (mean age 72 (± 4.2), 10 F) played a custom exergame that required repeated weight-shifts. Full-body 3D motion capture (3DMoCap) data and standard 2D digital video (2D-DV) was recorded. Weight shifting was directly measured by 3D ground reaction forces (GRF) from force plates, and estimated using a linear regression model, a long-short term memory (LSTM) model and a decision tree model (XGBoost). Performance was evaluated using coefficient of determination (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$R^2$$\end{document}R2) and root mean square error (RMSE).

Results

Results from estimation of GRF components using 3DMoCap data show a mean (± 1SD) RMSE (% total body weight, BW) of the vertical GRF component (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$F_z$$\end{document}Fz) of 4.3 (2.5), 11.1 (4.5), and 11.0 (4.7) for LSTM, XGBoost and LinReg, respectively. Using 2D-DV data, LSTM and XGBoost achieve mean RMSE (± 1SD) in \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$F_z$$\end{document}Fz estimation of 10.7 (9.0) %BW and 19.8 (6.4) %BW, respectively. \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$R^2$$\end{document}R2 was \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$>.97$$\end{document}>.97 for the LSTM in the \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$F_z$$\end{document}Fz component using 3DMoCap data, and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$>.77$$\end{document}>.77 using 2D-DV data. For XGBoost, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$F_z$$\end{document}Fz\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$R^2$$\end{document}R2 was \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$>.86$$\end{document}>.86 using 3DMoCap data, and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$>.56$$\end{document}>.56 using 2D-DV data.

Conclusion

This study demonstrates that an LSTM model can estimate 3-dimensional GRF components using 2D kinematic data extracted from standard 2D digital video cameras. The \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$F_z$$\end{document}Fz component is estimated more accurately than \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$F_y$$\end{document}Fy and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$F_x$$\end{document}Fx components, especially when using 2D-DV data. Weight-shifting performance during exergaming can thus be extracted using kinematic data only, which can enable effective independent in-home balance exergaming.

Data-Driven Classification of Human Movements in Virtual Reality-Based Serious Games: Preclinical Rehabilitation Study in Citizen Science

Background

Sustained engagement is essential for the success of telerehabilitation programs. However, patients’ lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science–based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR).

Objective

This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert.

Methods

In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users’ range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software’s response to their movements. During calibration, the time series of the users’ movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements.

Results

The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%).

Conclusions

Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation.

Design and Validation of Virtual Reality Task for Neuro-Rehabilitation of Distal Upper Extremities

Stroke, affecting approximately 15 million people worldwide, has long been a global cause of death and disability. Virtual Reality (VR) has shown its potential as an assistive tool for post-stroke rehabilitation. The objective of this pilot study was to define the task-specific performance metrics of VR tasks to assess the performance level of healthy subjects and patients quantitatively and to obtain their feedback for improving the developed framework. A pilot prospective study was designed. We tested the designed VR tasks on forty healthy right-handed subjects to evaluate its potential. Qualitative trajectory plots and three quantitative performance metrics—time taken to complete the task, percentage relative error, and trajectory smoothness—were computed from the recorded data of forty healthy subjects. Two patients with stroke were also enrolled to compare their performance with healthy subjects. Each participant received one VR session of 90 min. No adverse effects were noticed throughout the study. Performance metrics obtained from healthy subjects were used as a reference for patients. Relatively higher values of task completion time and trajectory smoothness and lower values of relative % error was observed for the affected hands w.r.t the unaffected hands of both the patients. For the unaffected hands of both the patients, the performance levels were found objectively closer to that of healthy subjects. A library of VR tasks for wrist and fingers were designed, and task-specific performance metrics were defined in this study. The evaluation of the VR exercises using these performance metrics will help the clinicians to assess the patient’s progress quantitatively and to design the rehabilitation framework for a future clinical study.

Physiotherapist beliefs and perspectives on virtual reality-supported rehabilitation for the assessment and management of musculoskeletal shoulder pain: a focus group study protocol

Shoulder pain accounts for a large proportion of musculoskeletal disorders and years lived with disability. Musculoskeletal shoulder pain is challenging to manage and while research evidence suggests that exercise should be a cornerstone of shoulder pain rehabilitation, the exact type and dosage of exercise is unclear. Adherence is a barrier to successful outcomes with exercise-based management of musculoskeletal pain, especially for those with co-morbidities, high pain levels and reported boredom associated with competing prescribed exercise. Virtual reality (VR) may offer an effective platform for rehabilitation of musculoskeletal shoulder pain. Virtual Reality has been shown to be effective for management of acute and chronic pain conditions, for delivering education around various health conditions, and for supporting rehabilitation of neurological conditions. Therefore, it is possible that VR may have a role in the delivery of exercise and education for individuals with musculoskeletal shoulder pain. VR intervention design should involve several steps and begin with establishing early acceptability from users as to the suitability of the technology in clinical practice as well as potential barriers and facilitators to using the technology successfully. This study will therefore aim to explore physiotherapists beliefs and perspectives of immersive VR as a platform for assessment and rehabilitation in patients with musculoskeletal shoulder pain. Further, this study will inform the development of a VR intervention for use in the rehabilitation of musculoskeletal shoulder pain. A series of online focus groups will be conducted with physiotherapists in Ireland using a qualitative descriptive approach to data analysis. A six-phase process of data analysis will be carried out to identify important patterns and themes within the data. The current study will be the first to explore clinician's perspectives on the role of VR in musculoskeletal practice.

The effects of virtual reality training in stroke and Parkinson's disease rehabilitation: a systematic review and a perspective on usability

Background

Virtual Reality (VR) training is emerging in the neurorehabilitation field. Technological advancement is often faster than clinical implementation. Previous reviews stressed the study design and methodological weaknesses of research in the field of VR for neurorehabilitation. Clinically relevant conclusions on implementation in particular patient groups are needed.

The aim was to update the existing knowledge with the recent evidence on the effects of VR training on functional ability of patients with stroke and Parkinson’s Disease (PD). Secondary objective was to analyze the aspects of usability of VR intervention in these populations.

Methods

Systematic literature search (via PubMed, CENTRAL) was conducted from inception to February 29, 2020 to identify suitable articles for two population subcategories. Randomized controlled trials published from 2016 to 2020, investigating the effectiveness of VR on a variety of outcomes contributing to the functional independence were included. Critical Appraisal Skills Programme (CASP) checklist was used for a methodological quality assessment of the primary studies. Given the heterogeneity in types of VR intervention and outcomes, a descriptive synthesis was conducted.

Results

A total of 18 randomized controlled trials were included (10 in stroke subcategory, 8 in PD). CASP grading ranged 9–11, suggesting high methodological quality. All studies concluded that overall VR might be as effective as the conventional training, but more motivating. In some studies, VR was found to have a greater effect, taking the high response to treatment and satisfaction into account.

Conclusions

VR training is suggested as an effective intervention to improve the functional ability in stroke and PD patients. Addition of VR into a rehabilitation program might facilitate patient’s motivation, participation and improvement, as this method was generally well accepted, and the results of trials were promising. The consideration of disorder-specific aspects should take place during the decision-making of VR implementation.

The Effect of Virtual Reality on Motor Anticipation and Hand Function in Patients with Subacute Stroke: A Randomized Trial on Movement-Related Potential

Background

Impaired cognitive ability to anticipate the required control for an upcoming task in patients with stroke may affect rehabilitation outcome. The cortical excitability of task-related motor anticipation for upper limb movement induced by virtual reality (VR) training remains unclear.

Aims

To investigate the effect of VR training on the cortical excitability of motor anticipation when executing upper limb movement in patients with subacute stroke.

Methods

A total of thirty-six stroke survivors with upper limb hemiparesis resulting from the first occurrence of stroke within 1 to 3 months were recruited. Participants were randomly allocated to the VR intervention group or conventional therapy group. Event-related potentials (ERPs) and electromyography (EMG) were used to simultaneously record the cortical excitability and muscle activities during palmar grasp motion. Outcome measures of the contingent negative variation (CNV) latency and amplitude, EMG reaction time, Upper Limb Fugl-Meyer Assessment (UL-FMA), Action Research Arm Test (ARAT), and National Institutes of Health Stroke Scale (NIHSS) were recorded pre- and postintervention. The between-group difference was analysed by mixed model ANOVA.

Results

The EMG onset time of the paretic hand in the VR group was earlier than that observed in the control group (t = 2.174, p = 0.039) postintervention. CNV latency reduction postintervention was larger in the VR group than in the control group (t = 2.411, p = 0.021) during paretic hand movement. The reduction in CNV amplitude in the VR group was larger in the VR group than in the control group (p < 0.001 for all electrodes except for C3) when executing paretic hand movement. ARAT and UL-FMA scores were significantly higher in the VR group than in the control group (p = 0.019 and p = 0.037, respectively) postintervention. No significant difference in the reduction in NIHSS was found between the VR and control groups (p = 0.072).

Conclusions

VR intervention is superior to conventional therapy to improve the cognitive neural process of motor anticipation and reduce the excessive compensatory activation of the contralesional hemisphere. The improvements observed in the cognitive neural process corroborated with the improvements in hand function.

Feasibility and acceptability of virtual reality for cancer pain in people receiving palliative care: a randomised cross-over study

CONTEXT

Pain management in palliative care remains inadequate; the development of innovative therapeutic options is needed.

OBJECTIVES

To determine the feasibility and preliminary effectiveness for larger randomised controlled trials of 3D head-mounted (HMD) virtual reality (VR) for managing cancer pain (CP) in adults.

METHODS

Thirteen people receiving palliative care participated in a single-session randomised cross-over trial, after which they completed a qualitative semi-structured interview. We also compared the effects of 3D HMD VR and 2D screen applications on CP intensity and levels of perceived presence. Feasibility was assessed with recruitment, completion rates and time required to recruit target sample.

RESULTS

Although recruitment was slow, completion rate was high (93%). Participants reported that the intervention was acceptable and caused few side effects. Although participants reported significantly reduced CP intensity after 3D HMD VR (1.9 ± 1.8, P = .003) and 2D screen applications (1.5 ± 1.6, P = .007), no significant differences were found between interventions (-.38 ± 1.2, 95% CI: -1.1-.29, P = .23). Participants reported significantly higher levels of presence with the 3D HMD VR compared to 2D screen (60.7 ± SD 12.4 versus 34.3 ± SD 17.1, mean 95% CI: 16.4-40.7, P = .001). Increased presence was associated with significantly lower pain intensity (mean 95% CI: -.04--0.01, P = 0.02).

CONCLUSIONS

Our preliminary findings support growing evidence that both 3D and 2D virtual applications provide pain relief for people receiving palliative care. Given the relative lack of cybersickness and increasing access to portable VR, we suggest that larger clinical studies are warranted.

Rehabilitation of Upper Limb Motor Impairment in Stroke: A Narrative Review on the Prevalence, Risk Factors, and Economic Statistics of Stroke and State of the Art Therapies

Stroke has been one of the leading causes of disability worldwide and is still a social health issue. Keeping in view the importance of physical rehabilitation of stroke patients, an analytical review has been compiled in which different therapies have been reviewed for their effectiveness, such as functional electric stimulation (FES), noninvasive brain stimulation (NIBS) including transcranial direct current stimulation (t-DCS) and transcranial magnetic stimulation (t-MS), invasive epidural cortical stimulation, virtual reality (VR) rehabilitation, task-oriented therapy, robot-assisted training, tele rehabilitation, and cerebral plasticity for the rehabilitation of upper extremity motor impairment. New therapeutic rehabilitation techniques are also being investigated, such as VR. This literature review mainly focuses on the randomized controlled studies, reviews, and statistical meta-analyses associated with motor rehabilitation after stroke. Moreover, with the increasing prevalence rate and the adverse socio-economic consequences of stroke, a statistical analysis covering its economic factors such as treatment, medication and post-stroke care services, and risk factors (modifiable and non-modifiable) have also been discussed. This review suggests that if the prevalence rate of the disease remains persistent, a considerable increase in the stroke population is expected by 2025, causing a substantial economic burden on society, as the survival rate of stroke is high compared to other diseases. Compared to all the other therapies, VR has now emerged as the modern approach towards rehabilitation motor activity of impaired limbs. A range of randomized controlled studies and experimental trials were reviewed to analyse the effectiveness of VR as a rehabilitative treatment with considerable satisfactory results. However, more clinical controlled trials are required to establish a strong evidence base for VR to be widely accepted as a preferred rehabilitation therapy for stroke.

Safety, Feasibility, and Acceptability of a New Virtual Rehabilitation Platform: A Supervised Pilot Study

Purpose:

Stroke is the leading cause of disability in adults worldwide, with hemiparesis being the most prevalent consequence. The use of video games and movement sensors could contribute to improving patients’ chances of recovery. We performed a supervised pilot study to validate the safety, feasibility, and acceptability of a new virtual rehabilitation platform in patients with chronic post-stroke upper limb hemiparesis.

Methods:

The participants (n = 9) participated in 40 rehabilitation sessions, twice a week, for a period of 20 weeks. Their experiences with the platform were documented using a Likert-scale survey. Changes in motor function were evaluated using the Chedoke Arm and Hand Activity Inventory (CAHAI) and the Wolf Motor Function Test (WMFT).

Results and conclusions:

All participants expressed that they enjoyed the experience and felt comfortable using the platform. Preliminary results showed significant motor recovery (P = .0039) according to the WMFT scores. Patients with significant impairment showed no improvement in upper limb task-oriented motor function after therapy.

The new platform is safe and well-accepted by patients. The improvement in motor function observed in some of the participants should be attributed to the therapy since spontaneous functional recovery is not expected in chronic stroke patients.

Changes in cerebral blood flow before, during, and after forward and backward walking in stroke patients trained using virtual reality walking videos with deliberately induced inaccuracies in walking speed estimations

[Purpose] The aim of this study was to examine the effects of virtual reality (VR) training, with deliberately induced inaccuracies in walking speed estimations, on brain activity. [Participants and Methods] The study participants were 21 stroke patients, and the walking tasks involved forward and backward walking. While the VR walking speed was set at 3 km/h, estimation errors were induced by using an actual walking speed of 1 km/h during the walking tasks. Cerebral blood flow was measured using two functional near-infrared spectroscopy (fNIRS) channels located over the left and right prefrontal cortices, to determine changes in oxyhemoglobin levels from the resting state. Cerebral hemodynamics were compared during and after the VR training. [Results] The backward walking task induced a significant increase in cerebral blood flow in the right prefrontal cortex during and after the VR training. No significant changes were observed during the forward walking task. [Conclusion] In the backward walking condition, greater activation of the right prefrontal cortex was observed during and immediately after the VR training. Watching VR may have led to inaccurate walking-speed estimations, necessitating postural control (which may be attributed to the activation of the prefrontal cortex) during walking.

Video game rehabilitation for outpatient stroke (VIGoROUS): A multi-site randomized controlled trial of in-home, self-managed, upper-extremity therapy

BACKGROUND

Integrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach.

METHODS

This completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850.

RESULTS

Of 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%.

INTERPRETATION

Self-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life.

FUNDING

PCORI, NIH.