Virtual reality for stroke rehabilitation

Virtual Reality Action Observation and Motor Imagery to Enhance Neuroplastic Capacity in the Human Motor Cortex: A Pilot Double-blind, Randomized Cross-over Trial

Neuroplasticity is important for learning, development and recovery from injury. Therapies that can upregulate neuroplasticity are therefore of interest across a range of fields. We developed a novel virtual reality action observation and motor imagery (VR-AOMI) intervention and evaluated whether it could enhance the efficacy of mechanisms of neuroplasticity in the human motor cortex of healthy adults. A secondary question was to explore predictors of the change in neuroplasticity following VR-AOMI. A pre-registered, pilot randomized controlled cross-over trial was performed. Twenty right-handed adults (13 females; mean age: 23.0 ± 4.53 years) completed two experimental conditions in separate sessions; VR-AOMI and control. We used intermittent theta burst stimulation (iTBS) to induce long term potentiation-like plasticity in the motor cortex and recorded motor evoked potentials at multiple timepoints as a measure of corticospinal excitability. The VR-AOMI task did not significantly increase the change in MEP amplitude following iTBS when compared to the control task (Group × Timepoint interaction p = 0.17). However, regression analysis identified the change in iTBS response following VR-AOMI was significantly predicted by the baseline iTBS response in the control task. Specifically, participants that did not exhibit the expected increase in MEP amplitude following iTBS in the control condition appear to have greater excitability following iTBS in the VR-AOMI condition (r = -0.72, p < 0.001). Engaging in VR-AOMI might enhance capacity for neuroplasticity in some people who typically do not respond to iTBS. VR-AOMI may prime the brain for enhanced neuroplasticity in this sub-group.

Feasibility of an exercise-nutrition-psychology integrated rehabilitation model based on mobile health and virtual reality for cancer patients: a single-center, single-arm, prospective phase II study

OBJECTIVE

Explore the feasibility of a mobile health(mHealth) and virtual reality (VR) based nutrition-exercise-psychology integrated rehabilitation model in Chinese cancer patients.

METHODS

We recruited cancer patients in the Oncology department of the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University from October 2022 to April 2023. The rehabilitation program was provided by a team of medical oncologists, dietitians, psychotherapists, and oncology specialist nurses. Participants received standard anti-cancer therapy and integrated intervention including hospitalized group-based exercise classes, at-home physical activity prescription, behavior change education, oral nutrition supplements, and psychological counseling. An effective intervention course includes two consecutive hospitalization and two periods of home-based rehabilitation (8 weeks). Access the feasibility as well as changes in aspects of physical, nutritional, and psychological status.

RESULTS

At the cutoff date of April 2023, the recruitment rate was 75% (123/165). 11.4%patients were lost to follow-up, and 3.25% withdrew halfway. Respectively, the completion rate of nutrition, exercise, and psychology were 85%,55%, and 63%. Nutrition interventions show the highest compliance. The parameters in nutrition, psychology, muscle mass, and quality of life after the rehabilitation showed significant improvements (P < .05). There was no significant statistical difference (P > .05) in handgrip strength and 6-minute walking speed.

CONCLUSION

It is feasible to conduct mHealth and VR-based nutrition-exercise-psychology integrated rehabilitation model in Chinese cancer patients. A larger multi-center trial is warranted in the future.

TRIAL REGISTRATION

ChiCTR2200065748 Registered 14 November 2022.

Effectiveness of Immersive Virtual Reality-Based Hand Rehabilitation Games for Improving Hand Motor Functions in Subacute Stroke Patients

Stroke rehabilitation faces challenges in attaining enduring improvements in hand motor function and is frequently constrained by interventional limitations. This research aims to present an innovative approach to the integration of cognitive engagement within visual feedback incorporated into fully immersive virtual reality (VR) based games to achieve enduring improvements. These innovative aspects of interaction provide more functional advantages beyond motivation to efficiently execute repeatedly hand motor tasks. The effectiveness of virtual reality games incorporated with innovative aspects has been investigated for improvements in hand motor functions. A randomized controlled trial was conducted, a total of (n=56) subacute stroke patients were assessed for eligibility and (n=52) patients fulfilled the inclusion criteria. (n=26) patients were assigned to the experimental group and (n=26) patients were assigned to the control group. VR intervention involves four VR based games, developed based on hand movements including flexion/extension, close/open, supination/pronation and pinch. All patients got therapy of 24 sessions, lasting 4 days/week for a total of 6 weeks. Five clinical outcome measures were Fugl- Meyer Assessment-Upper Extremity, Action Research Arm Test, Box and Block Test, Modified Barthel Index, and Stroke-Specific Quality of Life were assessed to evaluate patients' performance. Results revealed that after therapy there was significant improvement between the groups (p<0.05) and within groups (p<0.05) in all assessment weeks in all clinical outcome measures however, improvement was observed significantly greater in the experimental group due to fully immersive VR-based games. Results indicated that cognitive engagement within visual feedback incorporated in VR-based hand games effectively improved hand motor functions.

The efficacy of virtual reality for upper limb rehabilitation in stroke patients: a systematic review and meta-analysis

BACKGROUND

Stroke frequently gives rise to incapacitating motor impairments in the upper limb. Virtual reality (VR) rehabilitation has exhibited potential for augmenting upper extremity recovery; nonetheless, the optimal techniques for such interventions remain a topic of uncertainty. The present systematic review and meta-analysis were undertaken to comprehensively compare VR-based rehabilitation with conventional occupational therapy across a spectrum of immersion levels and outcome domains.

METHODS

A systematic search was conducted in PubMed, IEEE, Scopus, Web of Science, and PsycNET databases to identify randomized controlled trials about upper limb rehabilitation in stroke patients utilizing VR interventions. The search encompassed studies published in the English language up to March 2023. The identified studies were stratified into different categories based on the degree of immersion employed: non-immersive, semi-immersive, and fully-immersive settings. Subsequent meta-analyses were executed to assess the impact of VR interventions on various outcome measures.

RESULTS

Of the 11,834 studies screened, 55 studies with 2142 patients met the predefined inclusion criteria. VR conferred benefits over conventional therapy for upper limb motor function, functional independence, Quality of life, Spasticity, and dexterity. Fully immersive VR showed the greatest gains in gross motor function, while non-immersive approaches enhanced fine dexterity. Interventions exceeding six weeks elicited superior results, and initiating VR within six months post-stroke optimized outcomes.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that adjunctive VR-based rehabilitation enhances upper limb motor recovery across multiple functional domains compared to conventional occupational therapy alone after stroke. Optimal paradigms likely integrate VR's immersive capacity with conventional techniques.

TRIAL REGISTRATION

This systematic review and meta-analysis retrospectively registered in the OSF registry under the identifier [ https://doi.org/10.17605/OSF.IO/YK2RJ ].

The use of virtual reality for activities of daily living rehabilitation after brain injury: A scoping review

INTRODUCTION

Individuals with acquired brain injury (ABI) experience high rates of poor functional outcomes such as inability to complete activities of daily living (ADL). Occupational therapy needs to be customised to the individual's function, goals, and environment to facilitate improvement in ADLs after ABI. Virtual reality (VR) is a novel treatment approach that aims to improve skills within an individualised environment. This study aimed to review the current literature for the use of VR platforms that incorporate ADLs to improve functional outcomes after ABI.

METHODS

This review followed the six-stage framework by Arksey & O'Malley (2005). Electronic databases were searched for peer-reviewed journal articles based on inclusion and exclusion criteria.

RESULTS

One thousand and six hundred eighty articles were screened, including 413 full text articles and 13 articles were included for review. Among the 13 articles, six were RCTs and the rest were pre-post intervention studies. Studies largely used non-immersive VR platforms, which incorporated ADLs such as grocery shopping, aiming to improve functional outcomes.

CONSUMER AND COMMUNITY CONSULTATION

Consumer and community were not involved in executing this study.

CONCLUSION

This review suggests mixed results if VR is effective at treating upper limb, cognition, and ADL function after ABI. Using their clinical reasoning, occupational therapists can determine the suitability of VR for ADL rehabilitation for specific patient populations and settings. Plain Language Summary Individuals who sustain an acquired brain injury can have difficulty performing their daily activities such as, making a meal or getting dressed, because of limited function (e.g., physical and cognitive problems). To help improve their ability to complete daily activities, occupational therapy needs to be customised to the individual's function, goals, and environment. Virtual reality is a new rehabilitation approach that allows individuals to improve their function in an individualised environment. In this study, we reviewed the current studies that have used virtual reality platforms that incorporate daily activities to improve function after acquired brain injury. We searched databases and screened the titles and abstracts of 1,680 studies. Then, 413 full-text studies were screened, and 13 studies were included. Studies mostly used non-immersive platforms to practise daily activities such as, grocery shopping, aiming to improve function after acquired brain injury. This review suggests mixed results if virtual reality can effectively treat function after acquired brain injury.

Assistive Technology utilization among stroke survivors in Kano, Northwest Nigeria: A cross-sectional study

Mobility impairments and participation restrictions are common occurrences post-stroke, which may necessitate the need to utilize Assistive Technology (AT). This study investigated the prevalence, pattern, and satisfaction with AT utilization in stroke survivors (SS). The study was conducted in two hospitals in Kano, Nigeria. The QUBEC user evaluation of satisfaction with AT (QUEST) questionnaire and the Rivermead Mobility Index were used to assess satisfaction with AT utilization and mobility, respectively. Pearson correlation and independent t-test were used to determine the relationship and gender difference among the outcomes, respectively. A total of 280 SS participated; however, only 115 (41.07%) were AT users. The commonly used AT was wheelchair 84 (73%), while the least used was walking frame 3 (2.6%). About two-thirds of the participants were quite or very satisfied with their ATs. The duration of AT utilization is positively related to stroke duration (r = 0.940) but negatively related to mobility level (r = -0.246). There is no significant gender difference in duration and satisfaction with AT utilization. AT like wheelchairs seems uncommonly utilized among SS in Kano, Nigeria, likely due to patients' lack of knowledge of use, economic factors, and culture among others.

Navigating the Landscape of Telemedicine Research: A Topic Modeling Approach for the Present and Future

Introduction: Telemedicine, which is the provision of remote clinical services via telecommunication technology, has undergone an upsurge since the COVID-19 pandemic. To capture this paradigm, this study surveyed telemedicine literature, including postpandemic publications, to identify dominant research themes and temporal trends and suggest directions for future research. Methods: A corpus of 56,445 telemedicine studies is sourced from PubMed. Latent Dirichlet allocation (LDA) topic modeling performed using the Konstanz Information Miner platform. The textual data for topic modeling were processed by following standard procedures for natural language processing. Moreover, the term frequency-inverse document frequency approach was used to capture the importance of words within the corpus. We assessed perplexity, coherence, and the elbow method to determine the optimal number of topics for modeling. Results: The findings confirm the surge in telemedicine research after 2020, signifying its prominence. LDA topic modeling reveals seven distinct research themes, with the most prominent topic being "patient satisfaction" (21.38%) followed by "perspectives and challenges" (17.95%), and "smartphone apps" (14.32%). Furthermore, the results demonstrate a noticeable shift in topics from screening to therapeutic applications of telemedicine. Conclusions: This study serves as a guide for a broad range of telemedicine research topics. This synthesis of themes reflects the commitment of scholars to address the changing dynamics and health care needs, such as the COVID-19 pandemic, aging in place, smartphone usage, and technological advancement. The analysis also reveals flexible research responses to policy and contextual shifts, highlighting the collective drive to broaden the application of telemedicine in community health care.

Using virtual reality to manage pain and anxiety during dental treatments in patients with stroke: A case series

Dental anxiety is common post-stroke, with many patients unable to receive standard anesthetics. Virtual reality has been increasingly used to manage pain and anxiety in dentistry, though its use in individuals with stroke is largely unexplored. A case series of two patients with a history of stroke and dental anxiety was conducted at a specialized dental clinic. Patients watched 360°-virtual reality videos in a dental chair using a head-mounted display. Outcomes (patient: dental anxiety and pain, reactions to virtual reality; dental team: system usability, impact on workflow) were assessed using a standard observation tool, questionnaires, and interviews. Both patients wore virtual reality throughout the procedure and reported that the device was comfortable, provided a distraction, and had potential to reduce anxiety/pain. The dentist reported a positive impact on patient anxiety and time to complete procedures, and intends to continue using virtual reality with other stroke patients and clinical populations.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Exploring the Efficacy of Physiotherapy in Guillain-Barré Syndrome Through Virtual Reality-Based Rehabilitation: A Case Report

Guillain-Barré syndrome (GBS) refers to a spectrum of acute immune-mediated polyradiculoneuropathies, among which is acute motor axonal neuropathy (AMAN), which is typified by predominant motor involvement and axonal degeneration. This case study describes the presentation, diagnosis, and physiotherapy management using virtual reality-based technology in a 29-year-old male patient with AMAN. Nerve conduction velocity testing was used to diagnose motor axonal neuropathy in the patient, who had weakness subsequent to gastrointestinal symptoms. Intravenous immunoglobulin therapy was started, and a physiotherapy protocol was planned for eight weeks according to the patient's functional status. Physiotherapy plays an important role in the rehabilitation of patients with GBS, addressing the specific motor deficits and promoting recovery. The aim was to improve muscle strength, mobility, and functional independence through progressive exercises targeting specific motor deficits. Virtual reality-based training was also part of this rehabilitation process as an adjunct to conventional rehabilitation to improve dynamic balance and function of the upper and lower limbs, which showed significant improvement in the outcome measures.

Biochemical, biomechanical and imaging biomarkers of ischemic stroke: Time for integrative thinking

Stroke is one of the leading causes of adult disability affecting millions of people worldwide. Post-stroke cognitive and motor impairments diminish quality of life and functional independence. There is an increased risk of having a second stroke and developing secondary conditions with long-term social and economic impacts. With increasing number of stroke incidents, shortage of medical professionals and limited budgets, health services are struggling to provide a care that can break the vicious cycle of stroke. Effective post-stroke recovery hinges on holistic, integrative and personalized care starting from improved diagnosis and treatment in clinics to continuous rehabilitation and support in the community. To improve stroke care pathways, there have been growing efforts in discovering biomarkers that can provide valuable insights into the neural, physiological and biomechanical consequences of stroke and how patients respond to new interventions. In this review paper, we aim to summarize recent biomarker discovery research focusing on three modalities (brain imaging, blood sampling and gait assessments), look at some established and forthcoming biomarkers, and discuss their usefulness and complementarity within the context of comprehensive stroke care. We also emphasize the importance of biomarker guided personalized interventions to enhance stroke treatment and post-stroke recovery.

Efficacy of rTMS in treating functional impairment in post-stroke patients: a systematic review and meta-analysis

BACKGROUND

Most stroke patients suffer from an imbalance in blood supply, which causes severe brain damage leading to functional deficits in motor, sensory, swallowing, cognitive, emotional, and speech functions. Repetitive transcranial magnetic stimulation (rTMS) is thought to restore functions impaired during the stroke process and improve the quality of life of stroke patients. However, the efficacy of rTMS in treating post-stroke function impairment varies significantly. Therefore, we conducted a meta-analysis of the number of patients with effective rTMS in treating post-stroke dysfunction.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched. Screening and full-text review were performed by three investigators. Single-group rate meta-analysis was performed on the extracted data using a random variable model. Then subgroup analyses were performed at the levels of stroke acuity (acute, chronic, or subacute); post-stroke symptoms (including upper and lower limb motor function, dysphagia, depression, aphasia); rTMS stimulation site (affected side, unaffected side); and whether or not it was a combination therapy.

RESULTS

We obtained 8955 search records, and finally 33 studies (2682 patients) were included in the meta-analysis. The overall analysis found that effective strength (ES) of rTMS was 0.53. In addition, we found that the ES of rTMS from acute/subacute/chronic post-stroke was 0.69, 0.45, and 0.52. We also found that the ES of rTMS using high-frequency stimulation was 0.56, while the ES of rTMS using low-frequency stimulation was 0.53. From post-stroke symptoms, we found that the ES of rTMS in sensory aspects, upper limb functional aspects, swallowing function, and aphasia was 0.50, 0.52, 0.51, and 0.54. And from the site of rTMS stimulation, we found that the ES of rTMS applied to the affected side was 0.51, while the ES applied to the unaffected side was 0.54. What's more, we found that the ES of rTMS applied alone was 0.53, while the ES of rTMS applied in conjunction with other therapeutic modalities was 0.53.

CONCLUSIONS

By comparing the results of the data, we recommend rTMS as a treatment option for rehabilitation of functional impairment in patients after stroke. We also recommend that rehabilitation physicians or clinicians use combination therapy as one of the options for patients.

Systematic review of the effectiveness of innovative, gamified interventions for cognitive training in paediatric acquired brain injury

Effectiveness of innovative, gamified interventions (i.e., Augmented Reality, Computer-Based Cognitive Retraining [CBCR], and Virtual Reality [VR] in conjunction with a Serious Game) for cognitive training in paediatric ABI was evaluated. Studies were identified on PsycINFO, PubMed and Scopus; last searched 4 January 2022. Eligibility criteria were participants diagnosed with ABI and aged ≤ 18 years, experimental intervention to train cognition, cognition assessed pre- and post-intervention at: (1) The level of function, or (2) The level of activity, and written in English. ROB 2 and ROBINS-I were utilised to assess risk of bias. Extracted study characteristics were methods, participants, interventions, outcomes, and results. Seven studies were included, comprising six CBCR studies and one VR study, with 182 participants. Following CBCR: (1) Improvements were observed in several cognitive functions, but there was inconsistent evidence; (2) Improvements were reported in attention and executive functions (EF) at home and at school. Following VR: (1) Improvements were observed in attention and EF; (2) Not evaluated. Due to the small number of included studies with (relatively) small and heterogeneous samples, only a cautious interpretation of the evidence was provided. There is a need for carefully designed studies with more attention to inter-individual differences and generalisation to daily life.

The effect of Immersive Virtual Reality on balance: an exploratory study on the feasibility of head-mounted displays for balance evaluation

Global interest in applying virtual reality (VR) in research and medicine has grown significantly, with potential benefits for patients suffering from balance disorders, instability, and a high risk of falling. This exploratory study assesses the impact of immersive VR (IVR) delivered through a head-mounted display (HMD) on balance and explores the feasibility of using the HMD VR unit as a standalone posturography tool. Using the Meta Quest 2 HMD and a mid-range Android smartphone equipped with standard sensors, the research employed a VR environment that simulated a ship at sea, with thirty-eight healthy participants with no otoneurologic abnormalities. Measurements were conducted in repeated trials, including static assessments on both stable ground and foam, as well as a 3-m walk. This was conducted in two settings: one within a VR environment with three different intensity levels and the other in non-VR settings. Statistical analysis and clinical evaluation revealed that IVR with HMD influences head-level sway velocity, which correlates with increased visual disturbance, suggesting its potential as a low-risk standalone posturography tool.

Use of low-cost virtual reality in the treatment of the upper extremity in chronic stroke: a randomized clinical trial

BACKGROUND

Chronicity and lack of motivation often go together during the upper limb rehabilitation process in stroke. Virtual reality is a useful tool in this context, providing safe, intensive, individualised treatments in a playful environment. B-cost, easy-to-use devices with personalised and motivating games for a specific population seem to be the most effective option in the treatment of the upper limbs.

METHODS

A randomised clinical study with follow-up was carried out to assess the effectiveness of the Leap Motion Controller® device in improving the functionality of the upper limb in patients with chronic stroke. Patients (n = 36) were randomised into a control group that performed conventional therapy and an experimental group that combined the virtual reality protocol with conventional therapy. The outcome measures used were grip strength; the Block and Box Test; the Action Research Arm Test; the Disabilities of the Arm, Shoulder and Hand; as well as a Technology Satisfaction Questionnaire and adherence to treatment.

RESULTS

Inter-group statistical analysis showed no significant differences except in subsection D of the Action Research Arm Test. Intra-group analysis showed significant differences in both groups, but the experimental group reached significance in all long-term variables. Satisfaction and adherence levels were very high.

CONCLUSIONS

The Leap Motion Controller® system, as a complementary tool, produces improvements in grip strength, dexterity and motor function in patients with chronic stroke. It is perceived as a safe, motivating, and easy-to-use device.

CLINICAL REGISTRATION

NCT04166617 Clinical Trials.

Virtual Exercise in Medicine: A Proof of Concept in a Healthy Population

BACKGROUND

Science is beginning to establish the benefits of the use of virtual reality (VR) in health care. This therapeutic approach may be an appropriate complementary treatment for some mental illnesses. It could prevent high levels of morbidity and improve the physical health of patients. For many years, the literature has shown the health benefits of physical exercise. Physical exercise in a VR environment may improve the management of mild to moderate mental health conditions. In this context, we developed a virtual environment combined with an ergocycle (the augmented physical training for isolated and confined environments [APTICE] system).

OBJECTIVE

This study aims to investigate the impact of physical exercise in a VR environment.

METHODS

A total of 14 healthy participants (11 men and 3 women; mean age 43.28, SD 10.60 years) undertook 15 minutes of immersive physical exercise using the system. Measures included mindfulness and immersion disposition, subjective perceptions of sensory information, user experience, and VR experience (ie, psychological state, flow, and presence).

RESULTS

First, the APTICE system appears to be a useful tool because the user experience is positive (subscales in the AttrakDiff questionnaire: pragmatic quality=0.99; hedonic quality-stimulation=1.90; hedonic quality-identification=0.67; attractiveness=1.58). Second, the system can induce a positive psychological state (negative emotion, P=.06) and an experience of flow and presence (P values ranging from <.001 to .04). Third, individual immersive and mindful disposition plays a role in the VR experience (P values ranging from <.02 to .04). Finally, our findings suggest that there is a link between the subjective perception of sensory information and the VR experience (P values ranging from <.02 to .04).

CONCLUSIONS

These results indicate that the device is well accepted with positive psychological and exteroceptive outcomes. Overall, the APTICE system could be a proof of concept to explore the benefits of virtual physical exercise in clinical medicine.

Rehabilitation via HOMe-Based gaming exercise for the Upper limb post Stroke (RHOMBUS): a qualitative analysis of participants' experience

OBJECTIVE

To report participants' experiences of trial processes and use of the Neurofenix platform for home-based rehabilitation following stroke. The platform, consisting of the NeuroBall device and Neurofenix app, is a non-immersive virtual reality tool to facilitate upper limb rehabilitation following stroke. The platform has recently been evaluated and demonstrated to be safe and effective through a non-randomised feasibility trial (RHOMBUS).

DESIGN

Qualitative approach using semistructured interviews. Interviews were audio recorded, transcribed verbatim and analysed using the framework method.

SETTING

Participants' homes, South-East England.

PARTICIPANTS

Purposeful sample of 18 adults (≥18 years), minimum 12 weeks following stroke, not receiving upper limb rehabilitation prior to the RHOMBUS trial, scoring 9-25 on the Motricity Index (elbow and shoulder), with sufficient cognitive and communicative abilities to participate.

RESULTS

Five themes were developed which explored both trial processes and experiences of using the platform. Factors that influenced participant's decision to take part in the trial, their perceptions of support provided during the trial and communication with the research team were found to be important contextual factors effecting participants' overall experience. Specific themes around usability and comfort of the NeuroBall device, factors motivating persistence and perceived effectiveness of the intervention were highlighted as being central to the usability and acceptability of the platform.

CONCLUSION

This study demonstrated the overall acceptability of the platform and identified areas for enhancement which have since been implemented by Neurofenix. The findings add to the developing literature on the interface between virtual reality systems and user experience.

TRIAL REGISTRATION NUMBER

ISRCTN60291412.

Exploring Discussions About Virtual Reality on Twitter to Inform Brain Injury Rehabilitation: Content and Network Analysis

BACKGROUND

Virtual reality (VR) use in brain injury rehabilitation is emerging. Recommendations for VR development in this field encourage end user engagement to determine the benefits and challenges of VR use; however, existing literature on this topic is limited. Data from social networking sites such as Twitter may further inform development and clinical practice related to the use of VR in brain injury rehabilitation.

OBJECTIVE

This study collected and analyzed VR-related tweets to (1) explore the VR tweeting community to determine topics of conversation and network connections, (2) understand user opinions and experiences of VR, and (3) identify tweets related to VR use in health care and brain injury rehabilitation.

METHODS

Publicly available tweets containing the hashtags #virtualreality and #VR were collected up to twice weekly during a 6-week period from July 2020 to August 2020 using NCapture (QSR International). The included tweets were analyzed using mixed methods. All tweets were coded using inductive content analysis. Relevant tweets (ie, coded as "VR in health care" or "talking about VR") were further analyzed using Dann's content coding. The biographies of users who sent relevant tweets were examined descriptively. Tweet data networks were visualized using Gephi computational analysis.

RESULTS

A total of 260,715 tweets were collected, and 70,051 (26.87%) were analyzed following eligibility screening. The sample comprised 33.68% (23,596/70,051) original tweets and 66.32% (46,455/70,051) retweets. Content analysis generated 10 main categories of original tweets related to VR (ie, advertising and promotion, VR content, talking about VR, VR news, general technology, VR industry, VR live streams, VR in health care, VR events, and VR community). Approximately 4.48% (1056/23,596) of original tweets were related to VR use in health care, whereas 0.19% (45/23,596) referred to VR in brain injury rehabilitation. In total, 14.86% (3506/23,596) of original tweets featured commentary on user opinions and experiences of VR applications, equipment, and software. The VR tweeting community comprised a large network of 26,001 unique Twitter users. Users that posted tweets related to "VR in health care" (2124/26,001, 8.17%) did not form an interconnected VR network, whereas many users "talking about VR" (3752/26,001, 14.43%) were connected within a central network.

CONCLUSIONS

This study provides valuable data on community-based experiences and opinions related to VR. Tweets showcased various VR applications, including in health care, and identified important user-based considerations that can be used to inform VR use in brain injury rehabilitation (eg, technical design, accessibility, and VR sickness). Limited discussions and small user networks related to VR in brain injury rehabilitation reflect the paucity of literature on this topic and the potential underuse of this technology. These findings emphasize that further research is required to understand the specific needs and perspectives of people with brain injuries and clinicians regarding VR use in rehabilitation.

Multicentre pilot randomised control trial of a self-directed exergaming intervention for poststroke upper limb rehabilitation: research protocol

INTRODUCTION

Technology-facilitated, self-directed upper limb (UL) rehabilitation, as an adjunct to conventional care, could enhance poststroke UL recovery compared with conventional care alone, without imposing additional resource burden. The proposed pilot randomised controlled trial (RCT) aims to assess whether stroke survivors will engage in self-directed UL training, explore factors associated with intervention adherence and evaluate the study design for an RCT testing the efficacy of a self-directed exer-gaming intervention for UL recovery after stroke.

METHODS AND ANALYSIS

This is a multicentre, internal pilot RCT; parallel design, with nested qualitative methods. The sample will consist of stroke survivors with UL paresis, presenting within the previous 30 days. Participants randomised to the intervention group will be trained to use an exergaming device and will be supported to adopt this as part of their self-directed rehabilitation (ie, without formal support/supervision) for a 3-month period. The primary outcome will be the Fugl Meyer Upper Extremity Assessment (FM-UE) at 6 months poststroke. Secondary outcomes are the Action Research Arm Test (ARAT), the Barthel Index and the Modified Rankin Scale. Assessment time points will be prior to randomisation (0-1 month poststroke), 3 months and 6 months poststroke. A power calculation to inform sample size required for a definitive RCT will be conducted using FM-UE data from the sample across 0-6 months time points. Semistructured qualitative interviews will examine factors associated with intervention adoption. Reflexive thematic analysis will be used to code qualitative interview data and generate key themes associated with intervention adoption.

ETHICS AND DISSEMINATION

The study protocol (V.1.9) was granted ethical approval by the Health Research Authority, Health and Care Research Wales, and the London- Harrow Research Ethics Committee (ref. 21/LO/0054) on 19 May 2021. Trial results will be submitted for publication in peer-reviewed journals, presented at national and international stroke meetings and conferences and disseminated among stakeholder communities.

TRIAL REGISTRATION NUMBER

NCT04475692.

Design of Virtual Reality Exergames for Upper Limb Stroke Rehabilitation Following Iterative Design Methods: Usability Study

BACKGROUND

Since the early 2000s, there has been a growing interest in using exercise video games (exergames) and virtual reality (VR)-based interventions as innovative methods to enhance physical rehabilitation for individuals with multiple disabilities. Over the past decade, researchers and exercise professionals have focused on developing specialized immersive exercise video games for various populations, including those who have experienced a stroke, revealing tangible benefits for upper limb rehabilitation. However, it is necessary to develop highly engaging, personalized games that can facilitate the creation of experiences aligned with the preferences, motivations, and challenges communicated by people who have had an episode of stroke.

OBJECTIVE

This study seeks to explore the customization potential of an exergame for individuals who have undergone a stroke, concurrently evaluating its usability as a technological tool in the realm of physical therapy and rehabilitation.

METHODS

We introduce a playtest methodology to enhance the design of a VR exergame developed using a user-centered approach for upper limb rehabilitation in stroke survivors. Over 4 playtesting sessions, stroke survivors interacted with initial game versions using VR headsets, providing essential feedback for refining game content and mechanics. Additionally, a pilot study involving 10 stroke survivors collected data through VR-related questionnaires to assess game design aspects such as mechanics, assistance, experience, motion sickness, and immersion.

RESULTS

The playtest methodology was beneficial for improving the exergame to align with user needs, consistently incorporating their perspectives and achieving noteworthy results. The pilot study revealed that users had a positive response. In the first scenario, a carpenter presents a game based on the flexion-extension movement of the elbow; the second scenario includes a tejo game (a traditional Colombian throwing game) designed around game mechanics related to the flexion-extension movement of the shoulder; and in the third scenario, a farmer challenges the player to perform a movement combining elbow flexion and extension with internal and external rotation of the shoulder. These findings suggest the potential of the studied exergame as a tool for the upper limb rehabilitation of individuals who have experienced a stroke.

CONCLUSIONS

The inclusion of exergames in rehabilitation for stroke-induced hemiparesis has significantly benefited the recovery process by focusing on essential shoulder and elbow movements. These interactive games play a crucial role in helping users regain mobility and restore practical use of affected limbs. They also serve as valuable data sources for researchers, improving the system's responsiveness. This iterative approach enhances game design and markedly boosts user satisfaction, suggesting exergames have promising potential as adjunctive elements in traditional therapeutic approaches.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Systematic review registration

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

Effect of the VR-guided grasping task on the brain functional network

Virtual reality (VR) technology has been demonstrated to be effective in rehabilitation training with the assistance of VR games, but its impact on brain functional networks remains unclear. In this study, we used functional near-infrared spectroscopy imaging to examine the brain hemodynamic signals from 18 healthy participants during rest and grasping tasks with and without VR game intervention. We calculated and compared the graph theory-based topological properties of the brain networks using phase locking values (PLV). The results revealed significant differences in the brain network properties when VR games were introduced compared to the resting state. Specifically, for the VR-guided grasping task, the modularity of the brain network was significantly higher than the resting state, and the average clustering coefficient of the motor cortex was significantly lower compared to that of the resting state and the simple grasping task. Correlation analyses showed that a higher clustering coefficient, local efficiency, and modularity were associated with better game performance during VR game participation. This study demonstrates that a VR game task intervention can better modulate the brain functional network compared to simple grasping movements and may be more beneficial for the recovery of grasping abilities in post-stroke patients with hand paralysis.

ENHANCE proof-of-concept three-arm randomized trial: effects of reaching training of the hemiparetic upper limb restricted to the spasticity-free elbow range

Post-stroke motor recovery processes remain unknown. Timescales and patterns of upper-limb (UL) recovery suggest a major impact of biological factors, with modest contributions from rehabilitation. We assessed a novel impairment-based training motivated by motor control theory where reaching occurs within the spasticity-free elbow range. Patients with subacute stroke (≤ 6 month; n = 46) and elbow flexor spasticity were randomly allocated to a 10-day UL training protocol, either personalized by restricting reaching to the spasticity-free elbow range defined by the tonic stretch reflex threshold (TSRT) or non-personalized (non-restricted) and with/without anodal transcranial direct current stimulation. Outcomes assessed before, after, and 1 month post-intervention were elbow flexor TSRT angle and reach-to-grasp arm kinematics (primary) and stretch reflex velocity sensitivity, clinical impairment, and activity (secondary). Results were analyzed for 3 groups as well as those of the effects of impairment-based training. Clinical measures improved in both groups. Spasticity-free range training resulted in faster and smoother reaches, smaller (i.e., better) arm-plane path length, and closer-to-normal shoulder/elbow movement patterns. Non-personalized training improved clinical scores without improving arm kinematics, suggesting that clinical measures do not account for movement quality. Impairment-based training within a spasticity-free elbow range is promising since it may improve clinical scores together with arm movement quality.Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique Identifier: NCT02725853; Initial registration date: 01/04/2016.

Neurorehabilitation of the upper extremity - immersive virtual reality vs. electromechanically assisted training. A comparative study

Background

Severe paresis of the contralesional upper extremity is one of the most common and debilitating post-stroke impairments. The need for cost-effective high-intensity training is driving the development of new technologies, which can complement and extent conventional therapies. Apart from established methods using electromechanical devices, immersive virtual reality (iVR) systems hold promise to provide cost-efficient high-intensity arm training.

Objective

We investigated whether iVR-based arm training yields at least equivalent effects on upper extremity function as compared to an electromechanically assisted training in stroke patients with severe arm paresis.

Methods

52 stroke patients with severe arm paresis received a total of ten daily group therapy sessions over a period of three weeks, which consisted of 20 min of conventional therapy and 20 min of either electromechanically assisted (ARMEOSpring®) or iVR-based (CUREO®) arm training. Changes in upper extremity function was assessed using the Action Research Arm Test (ARAT) and user acceptance was measured with the User Experience Questionnaire (UEQ).

Results

iVR-based training was not inferior to electromechanically assisted training. We found that 84% of patients treated with iVR and 50% of patients treated with electromechanically assisted arm training showed a clinically relevant improvement of upper extremity function. This difference could neither be attributed to differences between the groups regarding age, gender, duration after stroke, affected body side or ARAT scores at baseline, nor to differences in the total amount of therapy provided.

Conclusion

The present study results show that iVR-based arm training seems to be a promising addition to conventional therapy. Potential mechanisms by which iVR unfolds its effects are discussed.

Exploring the efficacy of virtual reality-based rehabilitation in stroke: a narrative review of current evidence

BACKGROUND

Stroke rehabilitation presents a complex challenge, necessitating innovative approaches to optimise functional recovery. Virtual Reality-Based Rehabilitation (VRBR) has emerged as a promising intervention that capitalises on immersive technology to engage stroke survivors in their recovery journey. This review aims to examine the efficacy of VRBR in stroke rehabilitation, focusing on its advantages and challenges.

METHODS

A comprehensive search of relevant literature was conducted to gather evidence on the efficacy of VRBR in stroke survivors. Studies that investigated the impact of VRBR on patient engagement, functional recovery, and overall rehabilitation outcomes were included. The review also assessed the ability of VRBR to simulate real-life scenarios and facilitate essential daily activities for stroke survivors.

RESULTS

The review highlights that VRBR offers a unique immersive experience that enhances patient engagement and motivation during rehabilitation. The immersive nature of VRBR fosters a sense of presence, which can positively impact treatment adherence and outcomes. Moreover, VRBR's capacity to replicate real-world scenarios provides stroke survivors with opportunities to practice vital daily activities, promoting functional independence. In contrast, conventional rehabilitation methods lack the same level of engagement and real-world simulation.

CONCLUSION

VRBR holds promise as an efficacious intervention in stroke rehabilitation. Its immersive nature enhances patient engagement and motivation, potentially leading to better treatment adherence and outcomes. The ability of VRBR to simulate real-life scenarios offers a unique platform. However, challenges such as cost, equipment, patient suitability, data privacy, and acceptance must be addressed for successful integration into stroke rehabilitation practice.

Virtual Reality in Clinical Nursing Practice Over the Past 10 Years: Umbrella Review of Meta-Analyses

Background

Virtual reality (VR) has shown promising levels of effectiveness in nursing education, pain management, and rehabilitation. However, meta-analyses have discussed the effects of VR usage in nursing unilaterally and inconsistently, and the evidence base is diffuse and varied.

Objective

We aimed to synthesize the combined evidence from meta-analyses that assessed the effects of nurses using VR technology on nursing education or patient health outcomes.

Methods

We conducted an umbrella review by searching for meta-analyses about VR intervention in clinical nursing practice on Web of Science, Embase, Cochrane, and PubMed, and in reference lists. Eligible studies were published in English between December 1, 2012, and September 20, 2023. Meta-analyses of ≤2 intervention studies and meta-analyses without 95% CI or heterogeneity data were excluded. Characteristic indicators, population information, VR intervention information, and 95% CIs were extracted. A descriptive analysis of research results was conducted to discern relationships between VR interventions and outcomes. I2 and P values were used to evaluate publication bias. AMSTAR (A Measurement Tool to Assess Systematic Reviews) 2 and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) checklist were used to appraise literature quality.

Results

In total, 768 records were identified; 74 meta-analyses were included for review. The most reported VR study conditions were neuronursing (25/74, 34%), pediatric nursing (13/74, 18%), surgical and wound care (11/74, 15%), oncological nursing (11/74, 15%), and older adult nursing (10/74, 14%). Further, 30% (22/74) of meta-analyses reported publication bias, and 15% (11/74) and 8% (6/74) were rated as "high" based on AMSTAR 2 and the GRADE checklist, respectively. The main outcome indicators among all included meta-analyses were pain (37/214, 17.3%), anxiety (36/214, 16.8%), cognitive function (17/214, 7.9%), balance (16/214, 7.5%), depression (16/214, 7.5%), motor function (12/214, 5.6%), and participation in life (12/214, 5.6%). VR treatment for cognition, pain, anxiety, and depression was effective (all P values were <.05), while the utility of VR for improving motor function, balance, memory, and attention was controversial. Adverse effects included nausea, vomiting, and dizziness (incidence: range 4.76%-50%). The most common VR platforms were Pico VR glasses, head-mounted displays, the Nintendo Wii, and the Xbox Kinect. VR intervention duration ranged from 2 weeks to 12 months (typically ≥4 wk). VR session length and frequency ranged from 5 to 100 minutes and from 1 to 10 times per week, respectively.

Conclusions

VR in nursing has positive effects-relieving patients' pain, anxiety, and depression and improving cognitive function-despite the included studies' limited quality. However, applying VR in nursing to improve patients' motor function, balance, memory, and attention remains controversial. Nursing researchers need to further explore the effects and standard operation protocols of VR in clinical practice, and more high-quality research on VR in nursing is needed.

Medical Extended Reality Trials: Building Robust Comparators, Controls, and Sham

The explosive pace of development and research in medical extended reality (MXR) is a testament to its promise for health care and medicine. In comparison with this growth, there is a relative sparsity of rigorous clinical trials that establish the efficacy and effectiveness of these interventions. Explicating mechanisms of action across clinical areas and MXR applications is another major area of need. A primary impediment to these goals is a lack of frameworks for trial design, more specifically, the selection of appropriate controls that effectively address unique elements of MXR. This paper delineates a framework for designing controls, sham conditions, and comparators, as well as proposed considerations for MXR trial designs. Special consideration is given to the design of sham conditions. Improved designs would enable more robust findings and the development of generalizable knowledge that could be adopted across MXR interventions.

Evaluating the effectiveness of video-game based swallowing function training in patients with dysphagia: study protocol for a randomized controlled trial

BACKGROUND

Dysphagia can lead to serious complications such as aspiration and aspiration pneumonia, timely and effective rehabilitation training can improve the swallowing function of patients. However, the conventional rehabilitation training methods used in clinical settings have shortcomings such as poor adherence of patients. We present the study design of a randomized controlled trial that evaluated whether video-game based swallowing rehabilitation training can effectively improve swallowing in patients with dysphagia and whether it has additional benefits compared with conventional training methods to improve swallowing function and training compliance among patients with dysphagia.

METHODS

A randomized controlled trial with 4 weeks of intervention and 4 weeks of follow-up will be conducted in a rehabilitation center in Beijing, China. We will enroll 78 patients aged 18-80 years with dysphagia. Participants will be randomly assigned to the experimental group (video-game based swallowing function training) and the control group (conventional swallowing function training). All participants will receive 30 min of training per day, 5 times per week, for a total of 4 weeks. The primary outcome is swallowing function. Secondary outcomes include patients' quality of life, training compliance, and training satisfaction. Outcomes are assessed at baseline (pre-treatment), 4 weeks of treatment (post-treatment), and 8 weeks (follow-up), and the assessor is not aware of the participants' grouping.

DISCUSSION

The protocol describes a new rehabilitation training method for dysphagia, which involves participant eligibility recruitment, recruitment strategies, and data analysis plan. The results of the study will inform the rehabilitation training and clinical care management of swallowing function in patients with dysphagia.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05978700. Registered on 28 July 2023.

Action-rule-based cognitive control enables efficient execution of stimulus-response conflict tasks: a model validation of Simon task performance

Introduction

The human brain can flexibly modify behavioral rules to optimize task performance (speed and accuracy) by minimizing cognitive load. To show this flexibility, we propose an action-rule-based cognitive control (ARC) model. The ARC model was based on a stochastic framework consistent with an active inference of the free energy principle, combined with schematic brain network systems regulated by the dorsal anterior cingulate cortex (dACC), to develop several hypotheses for demonstrating the validity of the ARC model.

Methods

A step-motion Simon task was developed involving congruence or incongruence between important symbolic information (illustration of a foot labeled "L" or "R," where "L" requests left and "R" requests right foot movement) and irrelevant spatial information (whether the illustration is actually of a left or right foot). We made predictions for behavioral and brain responses to testify to the theoretical predictions.

Results

Task responses combined with event-related deep-brain activity (ER-DBA) measures demonstrated a key contribution of the dACC in this process and provided evidence for the main prediction that the dACC could reduce the Shannon surprise term in the free energy formula by internally reversing the irrelevant rapid anticipatory postural adaptation. We also found sequential effects with modulated dip depths of ER-DBA waveforms that support the prediction that repeated stimuli with the same congruency can promote remodeling of the internal model through the information gain term while counterbalancing the surprise term.

Discussion

Overall, our results were consistent with experimental predictions, which may support the validity of the ARC model. The sequential effect accompanied by dip modulation of ER-DBA waveforms suggests that cognitive cost is saved while maintaining cognitive performance in accordance with the framework of the ARC based on 1-bit congruency-dependent selective control.

Injured Avatars: The Impact of Embodied Anatomies and Virtual Injuries on Well-Being and Performance

Human cognition relies on embodiment as a fundamental mechanism. Virtual avatars allow users to experience the adaptation, control, and perceptual illusion of alternative bodies. Although virtual bodies have medical applications in motor rehabilitation and therapeutic interventions, their potential for learning anatomy and medical communication remains underexplored. For learners and patients, anatomy, procedures, and medical imaging can be abstract and difficult to grasp. Experiencing anatomies, injuries, and treatments virtually through one's own body could be a valuable tool for fostering understanding. This work investigates the impact of avatars displaying anatomy and injuries suitable for such medical simulations. We ran a user study utilizing a skeleton avatar and virtual injuries, comparing to a healthy human avatar as a baseline. We evaluate the influence on embodiment, well-being, and presence with self-report questionnaires, as well as motor performance via an arm movement task. Our results show that while both anatomical representation and injuries increase feelings of eeriness, there are no negative effects on embodiment, well-being, presence, or motor performance. These findings suggest that virtual representations of anatomy and injuries are suitable for medical visualizations targeting learning or communication without significantly affecting users' mental state or physical control within the simulation.

Rehabilitation Supported by Immersive Virtual Reality for Adults With Communication Disorders: Semistructured Interviews and Usability Survey Study

BACKGROUND

Individuals who have acquired communication disorders often struggle to transfer the skills they learn during therapy sessions to real-life situations. Immersive virtual reality (VR) technology has the potential to create realistic communication environments that can be used both in clinical settings and for practice at home by individuals with communication disorders.

OBJECTIVE

This research aims to enhance our understanding of the acceptance, usefulness, and usability of a VR application (SIM:Kitchen), designed for communication rehabilitation. Additionally, this research aims to identify the perceived barriers and benefits of using VR technology from the perspective of individuals with acquired communication disorders.

METHODS

Semistructured interviews and usability surveys were conducted with 10 individuals with acquired neurogenic communication disorders aged 46-81 (mean 58, SD 9.57) years after trialing an immersive VR application. The audio-recorded interviews were transcribed and analyzed to identify themes.

RESULTS

The quantitative data regarding the usability of the system associated with participants' immersion experience in the VR application were promising. Findings from semistructured interviews are discussed across five key thematic areas including (1) participant's attitude toward VR, (2) perceived usefulness of the VR system, (3) perceived ease of use of the VR system, (4) their willingness to continue using VR, and (5) the factors they perceived as challenges or facilitators to adopting this VR technology.

CONCLUSIONS

Overall, participants in this study found the VR experience to be enjoyable and were impressed by the realism of the VR application designed for communication rehabilitation. This study highlighted personally relevant, immersive VR interventions with different levels of task difficulty that could enhance technology uptake in the context of communication rehabilitation. However, it is essential that VR hand controller technology is refined to be more naturalistic in movement and able to accommodate user capabilities.

Factors associated with the effectiveness of immersive virtual therapy in alleviating depressive symptoms during sub-acute post-stroke rehabilitation: a gender comparison

BACKGROUND

The large-scale digitalization of healthcare has induced shifts in patient preferences, prompting the introduction of therapies utilizing novel technologies. In this context, the targeted application of these interventions is deemed as crucial as assessing their overall effectiveness. The aim of this study was to characterize the patient profile who benefited most from immersive virtual reality (VR) therapy.

METHODS

Based on the results from the previous randomized controlled trial study, we employed an exploratory study design to determine the factors associated with the most significant mental health improvement. A secondary analysis was conducted on a sample of 83 participants, with further analysis of participants with elevated depression symptoms, as indicated by a score of > 10 on the 30-item Geriatric Depression Scale (GDS-30). Both groups participated in a similar post-stroke rehabilitation program; however, the experimental group also received additional VR therapy through an immersive VR garden intervention. The GDS-30 was used to assess mood and depressive symptoms, and sociodemographic, cognitive status as well as stroke-related variables were considered as potential factors.

RESULTS

In both the experimental (mean change 5.3) and control groups (mean change 2.8), interventions significantly reduced depressive symptoms, with a more pronounced difference in the experimental group (p < 0.05). When examining gender differences, women exhibited greater improvement in the GDS, with mean between-group differences of 5.0 for the total sample and 6.0 for those with elevated depressive symptoms. Sociodemographic factors, cognitive status, and time from stroke were not found to be factors that alter the effectiveness of VR therapy.

CONCLUSIONS

While VR therapy as an adjunctive treatment for post-stroke rehabilitation seems especially effective for women with elevated depressive symptoms, the results should be interpreted with caution due to the study's small experimental group size. Traditional methods showed reduced effectiveness in women compared to men; thus, developing technologically advanced and gender-specific approaches can lead to more tailored therapy.

TRIAL REGISTRATION

NCT03830372 (February 5, 2019).

Proposal of neural network model for neurocognitive rehabilitation and its comparison with fuzzy expert system model

This article focuses on the development of algorithms for a smart neurorehabilitation system, whose core is made up of artificial neural networks. The authors of the article have proposed a completely unique transfer of ACE-R results to the CHC model. This unique approach allows for the saturation of the CHC model domains according to modified ACE-R factor analysis. The outputs of the proposed algorithm thus enable the automatic creation of a personalized and optimized neurorehabilitation plan for individual patients to train their cognitive functions. A set of tasks in 6 levels of difficulty (level 1 to level 6) was designed for each of the nine CHC model domains. For each patient, the results of the ACE-R screening helped deter-mine the specific CHC domains to be rehabilitated, as well as the initial gaming level for rehabilitation in each domain. The proposed artificial neural network algorithm was adapted to real data from 703 patients. Experimental outputs were compared to the outputs of the initially designed fuzzy expert system, which was trained on the same real data, and all outputs from both systems were statistically evaluated against expert conclusions that were available. It is evident from the conducted experimental study that the smart neurorehabilitation system using artificial neural networks achieved significantly better results than the neurorehabilitation system whose core is a fuzzy expert system. Both algorithms are implemented into a comprehensive neurorehabilitation portal (Eddie), which was supported by a research project from the Technology Agency of the Czech Republic.

Serious Game for Fine Motor Control Rehabilitation for Children With Epileptic Encephalopathy: Development and Usability Study

BACKGROUND

Epileptic encephalopathy (EE) is defined as the presence of frequent epileptiform activity that adversely impacts development, typically causing the slowing or regression of developmental skills, and is usually associated with frequent seizures. One of the main disturbances in EE is in the coordination of the upper extremities and hands. Traditional rehabilitation for this type of pathology focuses on the alleviation of gross or fine motor disability. In the last few years, the use of low-cost devices together with customized serious games has shown improvements in motor disorders and enrichments in activities of daily living.

OBJECTIVE

This study aims to explore the feasibility of a new serious game for improving fine motor control in children with EE.

METHODS

The participants were 4 children with EE (male: n=2, 50%; female: n=2, 50%) who were classified as belonging to level 1 in the Gross Motor Classification System. The children were tested over 10 sessions during the intervention period (before and after treatment). The clinical tests performed were the Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition and Pittsburgh Rehabilitation Participation Scale. The subscales of the Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition were fine motor precision, fine motor integration, manual dexterity, and upper-limb coordination. At the end of the first session, we used the User Satisfaction Evaluation Questionnaire to analyze user satisfaction.

RESULTS

The significance outcomes for a Student t test (1-tailed) were as follows: P=.009 for fine motor precision, P=.002 for fine motor integration, P=.56 for manual dexterity, and P=.99 for upper-limb coordination. The participation rate as measured using the Pittsburgh Rehabilitation Participation Scale was between good and very good, which means that, based on the therapist's evaluation, interest, independence, and motivation were achieved by each participant. The mean User Satisfaction Evaluation Questionnaire score was close to 30, which is the maximum value.

CONCLUSIONS

The results support the use of the proposed serious game as a complement in therapeutic sessions during the rehabilitation processes for children with EE. Significant improvements in fine motor control and activities of daily living revealed that the proposed serious game is beneficial for fine motor disorders of this pathology.

Development of Immersive Virtual Reality-Based Hand Rehabilitation System Using a Gesture-Controlled Rhythm Game With Vibrotactile Feedback: An fNIRS Pilot Study

Recently, virtua reality (VR) has been widely utilized with rehabilitation to promote user engagement, which has been shown to induce brain plasticity. In this study, we developed a VR-based hand rehabilitation system consisting of a personalized gesture-controlled rhythm game with vibrotactile feedback and investigated the cortical activation pattern induced by our system using functional near-infrared spectroscopy (fNIRS). Our system provides vibrotactile feedback as the user matches their hand gestures to VR targets customized to their pre-recorded hand gestures. Cortical activation was measured via fNIRS during 420 seconds of alternating gameplay and rest in 11 healthy subjects and one stroke survivor. Regions of interest (ROI) were the prefrontal cortex (PFC), the premotor cortex & the supplementary motor area (PMC&SMA), the primary sensorimotor cortex (SM1), and the somatosensory association cortex (SAC). The mean success rate of gesture matching among healthy subjects was 90 % with a standard deviation of 10.7 %, and the success rate of the stroke survivor was 79.6 %. The averaged cortical activation map for the 11 healthy subjects and the individual cortical activation map for the single stroke survivor showed increased hemodynamic responses of oxygenated hemoglobin (HbO) during the VR-based hand rehabilitation compared to the resting condition. Paired t-test analysis demonstrated a significant increase in HbO activation values in 19 out of 51 channels, corresponding to all ROIs except the left PFC and PMC&SMA, which exhibited high subject variability. The experimental results indicate that the proposed system successfully activated brain areas related to motor planning/execution, multisensory integration, and attention.

Challenges of neural interfaces for stroke motor rehabilitation

More than 85% of stroke survivors suffer from different degrees of disability for the rest of their lives. They will require support that can vary from occasional to full time assistance. These conditions are also associated to an enormous economic impact for their families and health care systems. Current rehabilitation treatments have limited efficacy and their long-term effect is controversial. Here we review different challenges related to the design and development of neural interfaces for rehabilitative purposes. We analyze current bibliographic evidence of the effect of neuro-feedback in functional motor rehabilitation of stroke patients. We highlight the potential of these systems to reconnect brain and muscles. We also describe all aspects that should be taken into account to restore motor control. Our aim with this work is to help researchers designing interfaces that demonstrate and validate neuromodulation strategies to enforce a contingent and functional neural linkage between the central and the peripheral nervous system. We thus give clues to design systems that can improve or/and re-activate neuroplastic mechanisms and open a new recovery window for stroke patients.

Bill-EVR: An Embodied Virtual Reality Framework for Reward-and-Error-Based Motor Rehab-Learning

VR rehabilitation is an established field by now, however, it often refers to computer screen-based interactive rehabilitation activities. In recent years, there was an increased use of VR-headsets, which can provide an immersive virtual environment for real-world tasks, but they are lacking any physical interaction with the task objects and any proprioceptive feedback. Here, we focus on Embodied Virtual Reality (EVR), an emerging field where not only the visual input via VR-headset but also the haptic feedback is physically correct. This happens because subjects interact with physical objects that are veridically aligned in Virtual Reality. This technology lets us manipulate motor performance and motor learning through visual feedback perturbations. Bill-EVR is a framework that allows interventions in the performance of real-world tasks, such as playing pool billiard, engaging end-users in motivating life-like situations to trigger motor (re)learning - subjects see in VR and handle the real-world cue stick, the pool table and shoot physical balls. Specifically, we developed our platform to isolate and evaluate different mechanisms of motor learning to investigate its two main components, error-based and reward-based motor adaptation. This understanding can provide insights for improvements in neurorehabilitation: indeed, reward-based mechanisms are putatively impaired by degradation of the dopaminergic system, such as in Parkinson's disease, while error-based mechanisms are essential for recovering from stroke-induced movement errors. Due to its fully customisable features, our EVR framework can be used to facilitate the improvement of several conditions, providing a valid extension of VR-based implementations and constituting a motor learning tool that can be completely tailored to the individual needs of patients.

Adaptive Neuroplasticity in Brain Injury Recovery: Strategies and Insights

This review addresses the relationship between neuroplasticity and recovery from brain damage. Neuroplasticity's ability to adapt becomes crucial since brain injuries frequently result in severe impairments. We begin by describing the fundamentals of neuroplasticity and how it relates to rehabilitation. Examining different forms of brain injuries and their neurological effects highlights the complex difficulties in rehabilitation. By revealing cellular processes, we shed light on synaptic adaptability following damage. Our study of synaptic plasticity digs into axonal sprouting, dendritic remodeling, and the balance of long-term potentiation. These processes depict neural resilience amid change. Then, after damage, we investigate immediate and slow neuroplastic alterations, separating reorganizations that are adaptive from those that are maladaptive. As we go on to rehabilitation, we evaluate techniques that use neuroplasticity's potential. These methods take advantage of the brain's plasticity for healing, from virtual reality and brain-computer interfaces to constraint-induced movement therapy. Ethics and individualized neurorehabilitation are explored. We scrutinize the promise of combination therapy and the difficulties in putting new knowledge into clinical practice. In conclusion, this analysis highlights neuroplasticity's critical role in brain injury recovery, providing sophisticated approaches to improve life after damage.

Ecologically valid virtual reality-based technologies for assessment and rehabilitation of acquired brain injury: a systematic review

Purpose

A systematic review was conducted to examine the state of the literature regarding using ecologically valid virtual environments and related technologies to assess and rehabilitate people with Acquired Brain Injury (ABI).

Materials and methods

A literature search was performed following the PRISMA guidelines using PubMed, Web of Science, ACM and IEEE databases. The focus was on assessment and intervention studies using ecologically valid virtual environments (VE). All studies were included if they involved individuals with ABI and simulated environments of the real world or Activities of Daily Living (ADL).

Results

Seventy out of 363 studies were included in this review and grouped and analyzed according to the nature of its simulation, prefacing a total of 12 kitchens, 11 supermarkets, 10 shopping malls, 16 streets, 11 cities, and 10 other everyday life scenarios. These VE were mostly presented on computer screens, HMD's and laptops and patients interacted with them primarily via mouse, keyboard, and joystick. Twenty-five out of 70 studies had a non-experimental design.

Conclusion

Evidence about the clinical impact of ecologically valid VE is still modest, and further research with more extensive samples is needed. It is important to standardize neuropsychological and motor outcome measures to strengthen conclusions between studies.

Systematic review registration

identifier CRD42022301560, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=301560.

Examining Usability, Acceptability, and Adoption of a Self-Directed, Technology-Based Intervention for Upper Limb Rehabilitation After Stroke: Cohort Study

BACKGROUND

Upper limb (UL) recovery after stroke is strongly dependent upon rehabilitation dose. Rehabilitation technologies present pragmatic solutions to dose enhancement, complementing therapeutic activity within conventional rehabilitation, connecting clinicians with patients remotely, and empowering patients to drive their own recovery. To date, rehabilitation technologies have been poorly adopted. Understanding the barriers to adoption may shape strategies to enhance technology use and therefore increase rehabilitation dose, thus optimizing recovery potential.

OBJECTIVE

We examined the usability, acceptability, and adoption of a self-directed, exercise-gaming technology within a heterogeneous stroke survivor cohort and investigated how stroke survivor characteristics, technology usability, and attitudes toward technology influenced adoption.

METHODS

A feasibility study of a novel exercise-gaming technology for self-directed UL rehabilitation in early subacute stroke survivors (N=30) was conducted in an inpatient, acute hospital setting. Demographic and clinical characteristics were recorded; participants' performance in using the system (usability) was assessed using a 4-point performance rating scale (adapted from the Barthel index), and adherence with the system was electronically logged throughout the trial. The technology acceptance model was used to formulate a survey examining the acceptability of the system. Spearman rank correlations were used to examine associations between participant characteristics, user performance (usability), end-point technology acceptance, and intervention adherence (adoption).

RESULTS

The technology was usable for 87% (n=26) of participants, and the overall technology acceptance rating was 68% (95% CI 56%-79%). Participants trained with the device for a median of 26 (IQR 16-31) minutes daily over an enrollment period of 8 (IQR 5-14) days. Technology adoption positively correlated with user performance (usability) (ρ=0.55; 95% CI 0.23-0.75; P=.007) and acceptability as well as domains of perceived usefulness (ρ=0.42; 95% CI 0.09-0.68; P=.03) and perceived ease of use (ρ=0.46; 95% CI 0.10-0.74; P=.02). Technology acceptance decreased with increased global stroke severity (ρ=-0.56; 95% CI -0.79 to -0.22; P=.007).

CONCLUSIONS

This technology was usable and acceptable for the majority of the cohort, who achieved an intervention dose with technology-facilitated, self-directed UL training that exceeded conventional care norms. Technology usability and acceptability were determinants of adoption and appear to be mediated by stroke severity. The results demonstrate the importance of selecting technologies for stroke survivors on the basis of individual needs and abilities, as well as optimizing the accessibility of technologies for the target user group. Facilitating changes in stroke survivors' beliefs and attitudes toward rehabilitation technologies may enhance adoption. Further work is needed to understand how technology can be optimized to benefit those with more severe stroke.

Is a novel digital system for arm and hand rehabilitation suitable for stroke survivors? A qualitative process evaluation of OnTrack

OBJECTIVES AND DESIGN

National guidelines emphasise the need to enhance arm and hand recovery poststroke. OnTrack is a 12-week package aiming to address this need. Feasibility was evaluated in a single-arm feasibility study (reported separately). This paper presents findings from a nested process evaluation. The objectives were to explore users' experiences of OnTrack and fidelity of delivery, in order to inform a definitive trial of effectiveness and future delivery.

SETTING

Participants were interviewed in a range of settings in hospital, home or via telephone, at the end of their intervention cycle. Session observations for a selection of coaching sessions were carried out in person at home or remotely, post-COVID-19.

PARTICIPANTS

Eleven participants who completed the intervention following a stroke were interviewed. Seven coaching sessions were observed.

INTERVENTION

This process evaluation was part of a larger feasibility study of OnTrack, which involves setting movement targets and monitoring activity using a tracker on the wrist, motivational messaging via a Smartphone and self-management coaching. Preliminary analysis of data collected was conducted with a public and patient involvement group formed of stroke survivors. This informed changes in intervention delivery.

RESULTS

Participants reported finding the OnTrack programme beneficial, with the coaching role seen as particularly important. Participants found activity tracking motivating, but some noted discrepancies between tracked movement and what they considered useful activity. Motivational messages were sometimes irritating. Most felt ready to sustain their own activity practice at the end of the programme.

CONCLUSIONS

This process evaluation supported initial theoretical assumptions that OnTrack would enable activity practice through the use of remote monitoring. There was a strong emphasis on the coaching role as a mechanism of impact supporting the technological intervention. These findings will inform the next stages of delivery in a definitive trial.

TRIAL REGISTRATION NUMBER

NCT03944486.

Cognitive Training With Head-Mounted Display Virtual Reality in Neurorehabilitation: Pilot Randomized Controlled Trial

BACKGROUND

Neurological rehabilitation is technologically evolving rapidly, resulting in new treatments for patients. Stroke, one of the most prevalent conditions in neurorehabilitation, has been a particular focus in recent years. However, patients often need help with physical and cognitive constraints, whereby the cognitive domain in neurorehabilitation does not technologically exploit existing potential. Usually, cognitive rehabilitation is performed with pen and paper or on a computer, which leads to limitations in preparation for activities of daily living. Technologies such as virtual reality (VR) can bridge this gap.

OBJECTIVE

This pilot study investigated the use of immersive VR in cognitive rehabilitation for patients undergoing inpatient neurorehabilitation. The goal was to determine the difference in rehabilitation effectiveness between a VR serious game that combines everyday activities with cognitive paradigms and conventional computerized cognitive training. We hypothesized the superiority of the VR serious game regarding cognitive abilities and patient-reported outcomes as well as transfer to daily life.

METHODS

We recruited 42 patients with acute brain affection from a German neurorehabilitation clinic in inpatient care with a Mini Mental Status Test score >20 to participate in this randomized controlled trial. Participants were randomly assigned to 2 groups, with 1 receiving the experimental VR treatment (n=21). VR training consisted of daily life scenarios, for example, in a kitchen, focusing on treating executive functions such as planning and problem-solving. The control group (n=21) received conventional computerized cognitive training. Each participant received a minimum of 18 treatment sessions in their respective group. Patients were tested for cognitive status, subjective health, and quality of life before and after the intervention (Alters-Konzentrations-Test, Wechsler Memory Scale-Revised, Trail Making Test A and B, Tower of London-German version, Short Form 36, European Quality of Life 5 Dimensions visual analog scale, and Fragebogen zur Erfassung der Performance in VR).

RESULTS

Repeated-measures ANOVA revealed several significant main effects in the cognitive tests: Tower of London-German version (P=.046), Trail Making Test A (P=.01), and Wechsler Memory Scale-Revised (P=.006). However, post hoc tests revealed that the VR group showed significant improvement in the planning, executive control, and problem-solving domains (P=.046, Bonferroni P=.02). In contrast, no significant improvement in the control group between t₀ and t₁ was detected (all P>.05). Furthermore, a nonsignificant trend was observed in visual speed in the VR group (P=.09, Bonferroni P=.02).

CONCLUSIONS

The results of this pilot randomized controlled trial showed that immersive VR training in cognitive rehabilitation had greater effectiveness than the standard of care in treating patients experiencing stroke in some cognitive domains . These findings support the further use and study of VR training incorporating activities of daily living in other neurological disorders involving cognitive dysfunction.

TRIAL REGISTRATION

Federal Registry of Clinical Trials of Germany (DRKS) DRKS00023605; https://drks.de/search/de/trial/DRKS00023605.

Online detection of compensatory strategies in human movement with supervised classification: a pilot study

Introduction

Stroke survivors often compensate for the loss of motor function in their distal joints by altered use of more proximal joints and body segments. Since this can be detrimental to the rehabilitation process in the long-term, it is imperative that such movements are indicated to the patients and their caregiver. This is a difficult task since compensation strategies are varied and multi-faceted. Recent works that have focused on supervised machine learning methods for compensation detection often require a large training dataset of motions with compensation location annotations for each time-step of the recorded motion. In contrast, this study proposed a novel approach that learned a linear classifier from energy-based features to discriminate between healthy and compensatory movements and identify the compensating joints without the need for dense and explicit annotations.

Methods

Six healthy physiotherapists performed five different tasks using healthy movements and acted compensations. The resulting motion capture data was transformed into joint kinematic and dynamic trajectories. Inspired by works in bio-mechanics, energy-based features were extracted from this dataset. Support vector machine (SVM) and logistic regression (LR) algorithms were then applied for detection of compensatory movements. For compensating joint identification, an additional condition enforcing the independence of the feature calculation for each observable degree of freedom was imposed.

Results

Using leave-one-out cross validation, low values of mean brier score (<0.15), mis-classification rate (<0.2) and false discovery rate (<0.2) were obtained for both SVM and LR classifiers. These methods were found to outperform deep learning classifiers that did not use energy-based features. Additionally, online classification performance by our methods were also shown to outperform deep learning baselines. Furthermore, qualitative results obtained from the compensation joint identification experiment indicated that the method could successfully identify compensating joints.

Discussion

Results from this study indicated that including prior bio-mechanical information in the form of energy based features can improve classification performance even when linear classifiers are used, both for offline and online classification. Furthermore, evaluation compensation joint identification algorithm indicated that it could potentially provide a straightforward and interpretable way of identifying compensating joints, as well as the degree of compensation being performed.

Telehealth-Guided Virtual Reality for Recovery of Upper Extremity Function Following Stroke

This rater-blinded, randomized control trial (RCT) investigated the effectiveness of a Glove Rehabilitation Application for Stroke Patients (GRASP) virtual reality home exercise program (HEP) for upper extremity (UE) motor recovery following stroke. The GRASP system facilitates the use of the affected UE in simulated instrumental activities of daily living (IADLs). Participants were asked to use the system at home in asynchronous telehealth sessions 4 times per week over 8 weeks. A non-blinded occupational therapist (OT) provided synchronous telehealth visits biweekly. Analysis comparing pre- and post-assessment results for the Fugl-Meyer UE assessment (FMUE) shows a clinically important and statistically significant between-group difference for participants completing the GRASP HEP protocol compared with usual and customary care controls. Statistically significant and clinically important differences were also found in Motor Activity Log (MAL) scores. This evidence provides support for the effectiveness of home-based, IADL-focused, virtual reality therapy with telehealth support.

Tool mastering today - an interdisciplinary perspective

Tools have coined human life, living conditions, and culture. Recognizing the cognitive architecture underlying tool use would allow us to comprehend its evolution, development, and physiological basis. However, the cognitive underpinnings of tool mastering remain little understood in spite of long-time research in neuroscientific, psychological, behavioral and technological fields. Moreover, the recent transition of tool use to the digital domain poses new challenges for explaining the underlying processes. In this interdisciplinary review, we propose three building blocks of tool mastering: (A) perceptual and motor abilities integrate to tool manipulation knowledge, (B) perceptual and cognitive abilities to functional tool knowledge, and (C) motor and cognitive abilities to means-end knowledge about tool use. This framework allows for integrating and structuring research findings and theoretical assumptions regarding the functional architecture of tool mastering via behavior in humans and non-human primates, brain networks, as well as computational and robotic models. An interdisciplinary perspective also helps to identify open questions and to inspire innovative research approaches. The framework can be applied to studies on the transition from classical to modern, non-mechanical tools and from analogue to digital user-tool interactions in virtual reality, which come with increased functional opacity and sensorimotor decoupling between tool user, tool, and target. By working towards an integrative theory on the cognitive architecture of the use of tools and technological assistants, this review aims at stimulating future interdisciplinary research avenues.

Feasibility of a serious game system including a tangible object for post stroke upper limb rehabilitation: a pilot randomized clinical study

Introduction

Serious games can be used to provide intensive rehabilitation through attractive exercises as part of post-stroke rehabilitation. However, currently available commercial and serious games systems primarily train shoulder and elbow movements. These games lack the grasping and displacement components that are essential to improve upper limb function. For this reason, we developed a tabletop device that encompassed a serious game with a tangible object to rehabilitate combined reaching and displacement movements: the Ergotact system.

Objectives

The aim of this pilot study was to assess the feasibility and the short-term effects of a training program using the Ergotact prototype in individuals with chronic stroke.

Methods

Participants were assigned to one of two groups: a serious game training group (Ergotact) or a control training group (Self).

Results

Twenty-eight individuals were included. Upper limb function increased after the Ergotact training program, although not statistically significantly, and the program did not induce pain or fatigue, demonstrating its safety.

Conclusion

The Ergotact system for upper limb rehabilitation was well accepted and induced participant satisfaction. It complies with current recommendations for people with stroke to autonomously perform intensive active exercises in a fun context, in addition to conventional rehabilitation sessions with therapists.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03166020?term=NCT03166020&draw=2&rank=1, identifier NCT03166020.

Conventional Mirror Therapy versus Immersive Virtual Reality Mirror Therapy: The Perceived Usability after Stroke

Background

Stroke is a widespread and complex health issue, with many survivors requiring long-term rehabilitation due to upper-limb impairment. This study is aimed at comparing the perceived usability of two feedback-based stroke therapies: conventional mirror therapy (MT) and immersive virtual reality mirror therapy (VR).

Methods

The study involved 45 participants, divided into three groups: the stroke survivors (n = 15), stroke-free older adults (n = 15), and young controls (n = 15). Participants performed two tasks using both MT and VR in a semirandom sequence. Usability instruments (SUS and NASA-TLX) were applied at the end of the activities, along with two experience-related questions.

Results

The results indicated that both MT and VR had similar levels of perceived usability, with MT being more adaptable and causing less overall discomfort. Conversely, VR increased the perception of task difficulty and prevented participants from diverting their attention from the mirror-based feedback.

Conclusion

While VR was found to be less comfortable than MT, both systems exhibited similar perceived usability. The comfort levels of the goggles may play a crucial role in determining the usability of VR for upper limb rehabilitation after stroke.

Contralaterally EMG-triggered functional electrical stimulation during serious gaming for upper limb stroke rehabilitation: a feasibility study

Introduction

Virtual Reality/serious games (SG) and functional electrical stimulation (FES) therapies are used in upper limb stroke rehabilitation. A combination of both approaches seems to be beneficial for therapy success. The feasibility of a combination of SG and contralaterally EMG-triggered FES (SG+FES) was investigated as well as the characteristics of responders to such a therapy.

Materials and methods

In a randomized crossover trial, patients performed two gaming conditions: SG alone and SG+FES. Feasibility of the therapy system was assessed using the Intrinsic Motivation Inventory (IMI), the Nasa Task Load Index, and the System Usability Scale (SUS). Gaming parameters, fatigue level and a technical documentation was implemented for further information.

Results

In total, 18 patients after stroke (62.1 ± 14.1 years) with a unilateral paresis of the upper limb (MRC ≤4) were analyzed in this study. Both conditions were perceived as feasible. Comparing the IMI scores between conditions, perceived competence was significantly increased (z = -2.88, p = 0.004) and pressure/tension during training (z = -2.13, p = 0.034) was decreased during SG+FES. Furthermore, the task load was rated significantly lower for the SG+FES condition (z = -3.14, p = 0.002), especially the physical demand (z = -3.08, p = 0.002), while the performance was rated better (z = -2.59, p = 0.010). Responses to the SUS and the perceived level of fatigue did not differ between conditions (SUS: z = -0.79, p = 0.431; fatigue: z = 1.57, p = 0.115). For patients with mild to moderate impairments (MRC 3-4) the combined therapy provided no or little gaming benefit. The additional use of contralaterally controlled FES (ccFES), however, enabled severely impaired patients (MRC 0-1) to play the SG.

Discussion

The combination of SG with ccFES is feasible and well-accepted among patients after stroke. It seems that the additional use of ccFES may be more beneficial for severely impaired patients as it enables the execution of the serious game. These findings provide valuable implications for the development of rehabilitation systems by combining different therapeutic interventions to increase patients' benefit and proposes system modifications for home use.

Clinical trial registration

https://drks.de/search/en, DRKS00025761.