Virtual Reality Design for Stroke Rehabilitation

CFI: a VR motor rehabilitation serious game design framework integrating rehabilitation function and game design principles with an upper limb case

Virtual reality (VR) Rehabilitation holds the potential to address the challenge that patients feel bored and give up long-term rehabilitation training. Despite the introduction of gaming elements by some researchers in rehabilitation training to enhance engagement, there remains a notable lack of in-depth research on VR rehabilitation serious game design methods, particularly the absence of a concrete design framework for VR rehabilitation serious games. Hence, we introduce the Clinical-Function-Interesting (CFI): a VR rehabilitation serious game design framework, harmonizing rehabilitation function and game design theories. The framework initiates with clinic information, defining game functions through the functional decomposition of rehabilitation training. Subsequently, it integrates gaming elements identified through the analysis and comparison of related literature to provide enduring support for long-term training. Furthermore, VR side-effect and enhancement are considered. Building upon this design framework, we have developed an upper limb VR rehabilitation serious game tailored for mild to moderate stroke patients and aligned our framework with another developed VR rehabilitation serious game to validate its practical feasibility. Overall, the proposed design framework offers a systematic VR rehabilitation serious game design methodology for the VR rehabilitation field, assisting developers in more accurately designing VR rehabilitation serious games that are tailored to specific rehabilitation goals.

The influence of scaffolding on intrinsic motivation and autonomous adherence to a game-based, unsupervised home rehabilitation program for people with upper extremity hemiparesis due to stroke. A randomized controlled trial

Background

This parallel, randomized controlled trial examines intrinsic motivation, adherence and motor function improvement demonstrated by two groups of subjects that performed a twelve-week, home-based upper extremity rehabilitation program. Seventeen subjects played games presenting eight to twelve discrete levels of increasing difficulty. Sixteen subjects performed the same activities controlled by success algorithms that modify game difficulty incrementally.

Methods

33 persons 20 to 80 years of age, at least six months post stroke with moderate to mild hemiparesis were randomized using a random number generator into the two groups. They were tested using the Action Research Arm Test, Upper Extremity Fugl Meyer Assessment, Stroke Impact Scale and Intrinsic Motivation Inventory pre and post training. Adherence was measured using timestamps generated by the system. Subjects had the Home Virtual Rehabilitation System [1]systems placed in their homes and were taught to perform rehabilitation games using it. Subjects were instructed to train twenty minutes per day but were allowed to train as much as they chose. Subjects trained for twelve weeks without appointments and received intermittent support from study staff. Group outcomes were compared using ANOVA. Correlations between subject demographics and adherence, as well as motor outcome, were evaluated using Pearson Correlation Coefficients. Classification and Regression Tree (CART) models were generated to predict responders using demographics and baseline measures.

Results

There were 5 dropouts and no adverse events. The main effect of time was statistically significant for four of the five clinical outcome measures. There were no significant training group by time interactions. Measures of adherence did not differ between groups. 21 subjects from both groups, demonstrated clinically important improvements in UEFMA score of at least 4.25 points. Subjects with pre training UEFMA scores below 53.5 averaged a seven-point UEFMA increase. IMI scores were stable pre to post training.

Conclusions

Scaffolding did not have a meaningful impact on adherence or motor function improvement. A sparsely supervised program of game-based treatment in the home was sufficient to elicit meaningful improvements in motor function and activities of daily living. Common factors considered barriers to the utilization of telerehabilitation did not impact adherence or motor outcome.

Trial registration

Clinical Trials.gov - NCT03985761, Registered June 14, 2019.

Effects of Serious Games in Older Adults With Mild Cognitive Impairment

OBJECTIVE

The rising prevalence of mild cognitive impairment (MCI) has spurred interest in innovative cognitive rehabilitation approaches, including serious games. This review summarizes randomized clinical trials (RCTs) exploring the impact of serious games on MCI patients.

METHODS

We conducted a comprehensive data search using key terms such as "gamification," "digital therapy," "cognition," "mild cognitive impairment," and "Alzheimer's disease." We exclusively considered published RCTs, excluding animal studies and basic research.

RESULTS

We identified eight RCTs. Four RCTs examined the effects of serious games using cognitive training for MCI patients. Notably, one study found that non-specific training (Nintendo Wii) significantly enhanced cognitive function and quality of life compared to cognition-specific computer training (CoTras). Among the remaining three RCTs, one specifically demonstrated that personalized serious game-based cognitive training yielded superior cognitive outcomes and reduced depressive symptoms. One RCT focused on serious games incorporating physical exercise, highlighting the effectiveness of kinetic-based exergaming in enhancing overall cognition. Three RCT focused on combined cognitive training and physical exercise. A double-blind RCT revealed that progressive resistance training or standalone physical exercise outperformed the combined approach in improving executive function and global cognition. Two additional RCTs reported positive outcomes, including improvements in cognitive function and electroencephalogram patterns associated with game-based interventions.

CONCLUSION

Serious games, whether focusing on cognitive training, physical exercise, or a combination of both, have potential to improve cognitive and functional outcomes in individuals with MCI. Further research and standardization of protocols are needed to better understand the full potential of serious games in MCI.

Views of Specialist Clinicians and People With Multiple Sclerosis on Upper Limb Impairment and the Potential Role of Virtual Reality in the Rehabilitation of the Upper Limb in Multiple Sclerosis: Focus Group Study

BACKGROUND

Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Using virtual reality (VR) could be a solution to this challenge; however, there is a lack of reporting on the views of people with MS and clinicians on VR-based approaches and recommendations for games for rehabilitation.

OBJECTIVE

This study aims to identify common UL problems and their related current therapeutic approaches for people with MS, and to explore the opinions of people with MS and specialist clinicians on VR and obtain suggestions for the development and design of VR games.

METHODS

Separate focus groups were conducted with people with MS, recruited through the MS Society UK's research network, and clinicians, recruited through the MS Trust Therapists in MS network. A total of 10 people with MS (2 focus groups) and 8 clinicians (5 physiotherapists, 2 occupational therapists, and 1 MS nurse in 2 focus groups) were involved. The focus groups were recorded and transcriptions were analyzed using theme-based content analysis.

RESULTS

People with MS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many people with MS neglected UL exercise and found strategies for adapting to the UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a solution, as it was convenient for people with MS to access and it could provide a more engaging and disguised approach to exercise. There were shared concerns with cybersickness and disengagement with using VR approaches. Both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and people with MS suggesting more abstract activities.

CONCLUSIONS

VR was well received by both people with MS and clinicians for UL rehabilitation. Recommendations were made for the development of VR rehabilitation games which are personalized and customizable for the varying abilities of people with MS.

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.

Leveraging Emerging Technologies to Expand Accessibility and Improve Precision in Rehabilitation and Exercise for People with Disabilities

Physical rehabilitation and exercise training have emerged as promising solutions for improving health, restoring function, and preserving quality of life in populations that face disparate health challenges related to disability. Despite the immense potential for rehabilitation and exercise to help people with disabilities live longer, healthier, and more independent lives, people with disabilities can experience physical, psychosocial, environmental, and economic barriers that limit their ability to participate in rehabilitation, exercise, and other physical activities. Together, these barriers contribute to health inequities in people with disabilities, by disproportionately limiting their ability to participate in health-promoting physical activities, relative to people without disabilities. Therefore, there is great need for research and innovation focusing on the development of strategies to expand accessibility and promote participation in rehabilitation and exercise programs for people with disabilities. Here, we discuss how cutting-edge technologies related to telecommunications, wearables, virtual and augmented reality, artificial intelligence, and cloud computing are providing new opportunities to improve accessibility in rehabilitation and exercise for people with disabilities. In addition, we highlight new frontiers in digital health technology and emerging lines of scientific research that will shape the future of precision care strategies for people with disabilities.

The Use of Gamification in the Self-Management of Patients With Chronic Diseases: Scoping Review

BACKGROUND

Chronic disease self-management is a public health issue of worldwide concern, and gamification is an emerging strategy to improve patients' participation in chronic disease self-management. Some studies have summarized designs for the gamification of chronic disease self-management from the perspective of eHealth technology, but they have not mentioned differences in design methods, functions, and evaluation methods of gamified designs for self-management in different chronic diseases.

OBJECTIVE

This scoping review aims to synthesize the characteristics of realization forms, functions, and evaluation methods in chronic disease self-management gamification to improve self-management among the chronic disease population.

METHODS

We applied a methodological framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. As of January 7, 2023, we systematically searched 9 databases for relevant studies from January 2012 to December 2022. Related data were extracted based on the research questions. We calculated the frequencies, charted the quantitative data, and coded the extracted material for qualitative content analysis.

RESULTS

We retrieved 16,221 records, of which 70 (0.43%) met the eligibility criteria. In the included research, the target populations for gamified designs for self-management of chronic diseases included patients with stroke, cancer, diabetes, chronic obstructive pulmonary disease, coronary heart disease, obesity, and hypertension. Almost all studies mentioned technical support for gamification (68/70, 97%), mainly in the form of active video games (58/70, 83%); however, less than half of the studies mentioned the theoretical basis for gamification (31/70, 44%). There were 37 concepts or theories relevant to gamification design, most of which were in the field of psychology or were cross-disciplinary (n=33, 89%). Gamification for the self-management of chronic diseases has been widely recognized, including for promoting physical exercise and rehabilitation training (48/99, 48%), increasing initiative for symptom management (18/99, 18%), providing psychological support (14/99, 14%), improving cognitive function (12/99, 12%), and improving medication adherence (7/99, 7%). A total of 39 studies mentioned the gamification effect; however, we did not find a unified evaluation standard.

CONCLUSIONS

This scoping review focuses on gamification designs for chronic disease self-management and summarizes the realization forms and functions of gamification in self-management for different patient populations. With practice in a gamified internet-based environment, patients can not only master the knowledge and skills of self-management in fascinating scenarios but also benefit from gaming experience and make better health-related decisions in real life. It is worth noting that a comprehensive evaluation of the users as well as a personalized and targeted intervention should be developed before gamification.

TACTICS VR Stroke Telehealth Virtual Reality Training for Health Care Professionals Involved in Stroke Management at Telestroke Spoke Hospitals: Module Design and Implementation Study

BACKGROUND

Stroke management in rural areas is more variable and there is less access to reperfusion therapies, when compared with metropolitan areas. Delays in treatment contribute to worse patient outcomes. To improve stroke management in rural areas, health districts are implementing telestroke networks. The New South Wales Telestroke Service provides neurologist-led telehealth to 23 rural spoke hospitals aiming to improve treatment delivery and patient outcomes. The training of clinical staff was identified as a critical aspect for the successful implementation of this service. Virtual reality (VR) training has not previously been used in this context.

OBJECTIVE

We sought to develop an evidence-based VR training module specifically tailored for stroke telehealth. During implementation, we aimed to assess the feasibility of workplace deployment and collected feedback from spoke hospital staff involved in stroke management on training acceptability and usability as well as perceived training impact.

METHODS

The TACTICS VR Stroke Telehealth application was developed with subject matter experts. During implementation, both quantitative and qualitative data were documented, including VR use and survey feedback. VR hardware was deployed to 23 rural hospitals, and use data were captured via automated Wi-Fi transfer. At 7 hospitals in a single local health district, staff using TACTICS VR were invited to complete surveys before and after training.

RESULTS

TACTICS VR Stroke Telehealth was deployed to rural New South Wales hospitals starting on April 14, 2021. Through August 20, 2023, a total of 177 VR sessions were completed. Survey respondents (n=20) indicated a high level of acceptability, usability, and perceived training impact (eg, accuracy and knowledge transfer; mean scores 3.8-4.4; 5=strongly agree). Furthermore, respondents agreed that TACTICS VR increased confidence (13/18, 72%), improved understanding (16/18, 89%), and improved awareness (17/18, 94%) regarding stroke telehealth. A comparison of matched pre- and posttraining responses revealed that training improved the understanding of telehealth workflow practices (after training: mean 4.2, SD 0.6; before training: mean 3.2, SD 0.9; P<.001), knowledge on accessing stroke telehealth (mean 4.1, SD 0.6 vs mean 3.1, SD 1.0; P=.001), the awareness of stroke telehealth (mean 4.1, SD 0.6 vs mean 3.4, SD 0.9; P=.03), ability to optimally communicate with colleagues (mean 4.2, SD 0.6 vs mean 3.7, SD 0.9; P=.02), and ability to make improvements (mean 4.0, SD 0.6 vs mean 3.5, SD 0.9; P=.03). Remote training and deployment were feasible, and limited issues were identified, although uptake varied widely (0-66 sessions/site).

CONCLUSIONS

TACTICS VR Stroke Telehealth is a new VR application specifically tailored for stroke telehealth workflow training at spoke hospitals. Training was considered acceptable, usable, and useful and had positive perceived training impacts in a real-world clinical implementation context. Additional work is required to optimize training uptake and integrate training into existing education pathways.

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.

Case-Based Serious Gaming for Complication Management in Colorectal and Pancreatic Surgery: Prospective Observational Study

BACKGROUND

The potential risk and subsequent impact of serious complications after pancreatic and colorectal surgery can be significantly reduced through early recognition, correct assessment, and timely initiation of appropriate therapy. Serious gaming (SG) is an innovative teaching method that combines play with knowledge acquisition, increased concentration, and quick decision-making and could therefore be used for clinically oriented education.

OBJECTIVE

This study aims to develop a case-based SG platform for complication management in pancreatic and colorectal surgery, validate the application by comparing game courses of various professional groups in the health care sector, and test the acceptance of the developed platform in the context of clinical education by measuring levels of usability and applicability within the framework of a validity and usefulness analysis.

METHODS

In this observational trial, a novel SG for management of postoperative complications was developed and prospectively validated in a cohort of 131 human caregivers with varying experience in abdominal surgery. A total of 6 realistic patient cases were implemented, representing common complications after pancreatic and colorectal surgery. Cases were developed and illustrated using anonymized images, data, and histories of postoperative patients. In the prospective section of this study, following a brief case presentation, participants were asked to triage the virtual patient, make an initial suspected diagnosis, and design a 3-step management plan, throughout which the results of selected diagnostic and therapeutic actions were presented. Participants' proposed case management was compared to ideal case management according to clinical guidelines. Usability, applicability, validity, and acceptance of the application were assessed using the Trier Teaching Evaluation Inventory as part of a noncomparative analysis. In addition, a comparative analysis of conventional teaching and learning formats was carried out.

RESULTS

A total of 131 cases were answered. Physicians selected more appropriate therapeutic measures than nonphysicians. In the Trier Teaching Evaluation Inventory, design, structure, relevance, timeliness, and interest promotion were predominantly rated positively. Most participants perceived the application to be superior to conventional lecture-based formats (training courses, lectures, and seminars) in terms of problem-solving skills (102/131, 77.9%), self-reflection (102/131, 77.9%), and usability and applicability (104/131, 79.4%).

CONCLUSIONS

Case-based SG has educational potential for complication management in surgery and could thereby contribute to improvements in postoperative patient care.

The Extent of Evidence Supporting the Effectiveness of Extended Reality Telerehabilitation on Different Qualitative and Quantitative Outcomes in Stroke Survivors: A Systematic Review

Objective: To present the extent of evidence concerning the effectiveness of extended reality telerehabilitation and patients' experiences of using different types of virtual reality exercises at home. Methods: We included studies on virtual reality and augmented reality telerehabilitation published in English. Systematic searches were undertaken in PubMed, Web of Sciences, Medline, Embase, CINAHL, and PEDro, with no date limitations. We included only RCTs and qualitative studies exploring patients' experiences. Methodological quality was assessed using the Cochrane Risk of Bias assessment tool for quantitative papers and the CASP scale for qualitative studies. All results are presented narratively. Results: Thirteen studies, nine quantitative and four qualitative, were included, with one qualitative and seven quantitative having a high risk of bias. All studies reported that extended reality-based telerehabilitation may be effective compared to conventional exercises or other extended reality exercises. Seven quantitative studies focused on upper limb function. Qualitative papers suggested that VR exercises were perceived as feasible by patients. Conclusions: The literature suggests VR home exercises are feasible and potentially effective for patients after a stroke in the upper limb. Further high-quality studies are needed to examine the effectiveness of XR exercises early adoption on different qualitative and quantitative outcomes. Registration number: (CRD42022384356).

The effectiveness of virtual reality games in improving cognition, mobility, and emotion in elderly post-stroke patients: a systematic review and meta-analysis

This review is aimed to assess the effectiveness of virtual reality (VR) games on cognition, mobility, and emotion in elderly stroke patients. We selected relevant articles from eight databases from 2011 to 2022 and extracted articles on cognitive ability (general cognition, mini-mental state examination (MMSE), Montreal cognitive assessment (MoCA) et al.), mobility (modified Barthel index (MBI), Fugl-Meyer assessment (FMA), Berg balance scale (BBS), functional independence measure motor (FIM MOT)), and emotion (depression/anxiety). Twenty-nine studies including 1311 participants were included in the analysis. In the results, virtual reality games were more effective in improving overall cognitive function in stroke patients compared to conventional therapies. In addition, the intervention group in the MMSE (SMD = 0.6, 95%CI = 0.26-0.95, P = 0.0007), MoCA (MD = 1.97, 95%CI = 1.3-2.64, P < 0.00001), and attention test (MD = 0.25, 95% CI = 0.01-0.49, P < 0.00001) scores were also higher. In terms of physical function, MBI (SMD = 0.61, 95%CI = 0.14-1.08, P = 0.01), FMA (SMD = 0.47, 95%CI = 0.02-0.93, P = 0.04), BBS (SMD = 0.78, 95%CI = 0.42-1.15, P < 0.0001), and FIM MOT (MD = 5.87, 95%CI = 2.57-9.17, P = 0.0005) indicators showed better results. It is also observed that virtual reality games can effectively relieve depression and improve mental health in stroke patients. Sports game training, especially with VR equipment, had a positive impact on improving the cognitive performance, mobility, and emotional state of stroke patients compared to a control group. Although the improvement in cognitive ability is relatively low, the effect of improving physical activity and depression is obvious.

Impact of the built environment on stroke inpatient rehabilitation

Guidance recommends that people with disability following stroke should receive rehabilitation in a dedicated stroke inpatient unit. Previous research has indicated that aspects of the built environment in inpatient settings can impact on patient wellbeing and experience. This article evaluates and discusses the findings of a recent systematic review that explores the effect of environmental and design factors on stroke rehabilitation.

Virtual and Augmented Reality in Post-stroke Rehabilitation: A Narrative Review

Virtual reality (VR) and augmented reality (AR) are noble adjunctive technologies currently being studied for the neuro-rehabilitation of post-stroke patients, potentially enhancing conventional therapy. We explored the literature to find if VR/AR improves neuroplasticity in stroke rehabilitation for a better quality of life. This modality can lay the foundation for telerehabilitation services in remote areas. We analyzed four databases, namely Cochrane Library, PubMed, Google Scholar, and Science Direct, by searching the following keywords: ("Stroke Rehabilitation" [Majr]) AND ("Augmented Reality" [Majr]), Virtual Augmented Reality in Stroke Rehabilitation. All the available open articles were reviewed and outlined. The studies conclude that VR/AR can help in early rehabilitation and yield better results in post-stroke patients in adjunct to conventional therapy. However, due to the limited research on this subject, we cannot conclude that this information is absolute. Moreover, VR/AR was seldom customized according to the needs of stroke survivors, which would have given us the full extent of its application. Around the world, stroke survivors are being studied to verify the accessibility and practicality of these innovative technologies. Observations conclude that further exploration of the extent of the implementations and efficacy of VR and AR, combined with conventional rehabilitation, is fundamental.

Research Status and Emerging Trends in Virtual Reality Rehabilitation: Bibliometric and Knowledge Graph Study

BACKGROUND

Virtual reality (VR) technology has been widely used in rehabilitation training because of its immersive, interactive, and imaginative features. A comprehensive bibliometric review is required to help researchers focus on future directions based on the new definitions of VR technologies in rehabilitation, which reveal new situations and requirements.

OBJECTIVE

Herein, we aimed to summarize effective research methods for and potential innovative approaches to VR rehabilitation by evaluating publications from various countries to encourage research on efficient strategies to improve VR rehabilitation.

METHODS

The SCIE (Science Citation Index Expanded) database was searched on January 20, 2022, for publications related to the application of VR technology in rehabilitation research. We found 1617 papers, and we created a clustered network, using the 46,116 references cited in the papers. CiteSpace V (Drexel University) and VOSviewer (Leiden University) were used to identify countries, institutions, journals, keywords, cocited references, and research hot spots.

RESULTS

A total of 63 countries and 1921 institutes have contributed publications. The United States of America has taken the leading position in this field; it has the highest number of publications; the highest h-index; and the largest collaborative network, which includes other countries. The reference clusters of SCIE papers were divided into the following nine categories: kinematics, neurorehabilitation, brain injury, exergames, aging, motor rehabilitation, mobility, cerebral palsy, and exercise intensity. The research frontiers were represented by the following keywords: video games (2017-2021), and young adults (2018-2021).

CONCLUSIONS

Our study comprehensively assesses the current research state of VR rehabilitation and analyzes the current research hot spots and future trends in the field, with the aims of providing resources for more intensive investigation and encouraging more researchers to further develop VR rehabilitation.

Expressive Interaction Design Using Facial Muscles as Controllers

Here we describe a proof-of-concept case study focusing on the design and development of a novel computer interface that uses facial muscles to control interactivity within a virtual environment. We have developed a system comprised of skin-mounted electrodes that detect underlying muscle activity through electromyography. The signals from the electrodes are filtered and smoothed, then used as input data to an application that displays a virtual environment with a 3D animated avatar. The user’s expressions control the facial movements of the avatar, thus conveying user emotions through real-time animation of a representative face in a virtual scenario. To achieve this, we collaborated with our Public and Patient Involvement focus group to discuss concepts and design appropriate interactions, while simultaneously developing a prototype system. Programmers and 3D artists worked together to create a system whereby individual user facial muscles are connected to 3D animated models of the same muscle features represented in an avatar, providing the user with an option to receive visual and numerical feedback on the extent of their muscle control. Using the prototype system, people can communicate facial expressions virtually with each other, without the need for a camera. This research is part of an on-going project to develop a facial muscle rehabilitation system that can be optimized to help patients with conditions such as hypomimia.

Motor Rehabilitation of Upper Limbs Using a Gesture-Based Serious Game: Evaluation of Usability and User Experience

Objective: Gesture-based serious games can be based on playful and interactive scenarios to enhance user engagement and experience during exercises, thereby increasing efficiency in the motor rehabilitation process. This study aimed to develop the Rehabilite Game (RG) as a complementary therapy tool for upper limb rehabilitation in clinics and home environments and to evaluate aspects of usability and user experience of it. Materials and Methods: The evaluation consisted of the use of a gesture-based serious game with motor rehabilitation sessions managed in a web platform. Thirty-three participants were recruited (21 physiotherapists and 12 patients). The protocol allowed each participant to have the experience of playing sessions with different combinations of settings. The User Experience Questionnaire (UEQ) was used to evaluate aspects of usability and user experience. The study was approved by the Research Ethics Board of the Federal University of Piaui (number 3,429,494). Results: The level of satisfaction with the RG was positive, with an excellent Net Promoter Score for 85.7% of physiotherapists and 100% of patients. All six UEQ scales (attractiveness, perspicuity, efficiency, dependability, stimulation, and novelty) reflected acceptance. Conclusion: The study demonstrated that, according to the results obtained in the experiments, the RG had positive feedback from physiotherapists and patients, indicating that the game can be used in a clinical trial to be compared with other rehabilitation techniques.

The effect of virtual reality on executive function in older adults with mild cognitive impairment: a systematic review and meta-analysis

OBJECTIVES

This review aimed to summarize the currently available premium evidence to determine the effect of virtual reality (VR) on executive function (EF) in older adults with mild cognitive impairment (MCI), and to detect what level of immersive VR would be the most beneficial.

METHOD

Five electronic databases, namely, PubMed, Embase, PsycINFO, CINAHL, and Cochrane Library were searched. Our research team screened the studies and extracted data according to our inclusion criteria. The methodological quality of each study was rated using the PEDro scale. When three or more studies reported the same outcome, a meta-analysis was conducted using Review Manager 5.4.1.

RESULTS

Finally, 14 randomized controlled trials with a total of 518 participants were included. VR training had an overall positive effect on cognitive flexibility, global cognitive function, attention, and short-term memory compared to the control groups. Additionally, semi-immersive VR was more effective in improving cognitive flexibility compared to the other two types of VR. The application of non-immersive level of VR had a significant effect on global cognitive function, attention, short-term memory, and cognitive flexibility.

CONCLUSION

VR may be effective in improving EF in older adults with MCI. However, the level of immersive VR that would be the most beneficial on EF still needs to be investigated with a greater number of well-designed studies.

Development and Pilot Implementation of TACTICS VR: A Virtual Reality-Based Stroke Management Workflow Training Application and Training Framework

Delays in acute stroke treatment contribute to severe and negative impacts for patients and significant healthcare costs. Variability in clinical care is a contributor to delayed treatment, particularly in rural, regional and remote (RRR) areas. Targeted approaches to improve stroke workflow processes improve outcomes, but numerous challenges exist particularly in RRR settings. Virtual reality (VR) applications can provide immersive and engaging training and overcome some existing training barriers. We recently initiated the TACTICS trial, which is assessing a "package intervention" to support advanced CT imaging and streamlined stroke workflow training. As part of the educational component of the intervention we developed TACTICS VR, a novel VR-based training application to upskill healthcare professionals in optimal stroke workflow processes. In the current manuscript, we describe development of the TACTICS VR platform which includes the VR-based training application, a user-facing website and an automated back-end data analytics portal. TACTICS VR was developed via an extensive and structured scoping and consultation process, to ensure content was evidence-based, represented best-practice and is tailored for the target audience. Further, we report on pilot implementation in 7 Australian hospitals to assess the feasibility of workplace-based VR training. A total of 104 healthcare professionals completed TACTICS VR training. Users indicated a high level of usability, acceptability and utility of TACTICS VR, including aspects of hardware, software design, educational content, training feedback and implementation strategy. Further, users self-reported increased confidence in their ability to make improvements in stroke management after TACTICS VR training (post-training mean ± SD = 4.1 ± 0.6; pre-training = 3.6 ± 0.9; 1 = strongly disagree, 5 = strongly agree). Very few technical issues were identified, supporting the feasibility of this training approach. Thus, we propose that TACTICS VR is a fit-for-purpose, evidence-based training application for stroke workflow optimisation that can be readily deployed on-site in a clinical setting.

Digital health in stroke medicine: what are the opportunities for stroke patients?

PURPOSE OF REVIEW

The European Stroke Organisation published a European Stroke Action Plan (SAP-E) for the years 2018-2030. The SAP-E addresses the entire chain of care from primary prevention through to life after stroke. Within this document digital health tools are suggested for their potential to facilitate greater access to stroke care. In this review, we searched for digital health solutions for every domain of the SAP-E.

RECENT FINDINGS

Currently available digital health solutions for the cerebrovascular disease have been designed to support professionals and patients in healthcare settings at all stages. Telemedicine in acute settings has notably increased the access to tissue plasminogen activator and thrombectomy whereas in poststroke settings it has improved access to rehabilitation. Moreover, numerous applications aim to monitor vital signs and prescribed treatment adherence.

SUMMARY

SAP-E with its seven domains covers the whole continuum of stroke care, where digital health solutions have been considered to provide utility at a low cost. These technologies are progressively being used in all phases of stroke care, allowing them to overcome geographical and organizational barriers. The commercially available applications may also be used by patients and their careers in various context to facilitate accessibility to health improvement strategies.

VIRTUAL REALITY TRAINING THROUGH NINTENDO WII GAMES IN STROKE PATIENTS: A RANDOMISED CLINICAL TRIAL (Preprint)

Background

Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial.

Objective

The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke.

Methods

It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22.

Results

The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted.

Conclusions

VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability.

Trial Registration

Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view

Virtual Reality Augmented Feedback Rehabilitation Associated to Action Observation Therapy in Buccofacial Apraxia: Case Report

Background:

Buccofacial Apraxia is defined as the inability to perform voluntary movements of the larynx, pharynx, mandible, tongue, lips and cheeks, while automatic or reflexive control of these structures is preserved. Buccofacial Apraxia frequently co-occurs with aphasia and apraxia of speech and it has been reported as almost exclusively resulting from a lesion of the left hemisphere. Recent studies have demonstrated the benefit of treating apraxia using motor training principles such as Augmented Feedback or Action Observation Therapy. In light of this, the study describes the treatment based on immersive Action Observation Therapy and Virtual Reality Augmented Feedback in a case of Buccofacial Apraxia.

Participant and Methods:

The participant is a right-handed 58-years-old male. He underwent a neurosurgery intervention of craniotomy and exeresis of infra axial expansive lesion in the frontoparietal convexity compatible with an atypical meningioma. Buccofacial Apraxia was diagnosed by a neurologist and evaluated by the Upper and Lower Face Apraxia Test. Buccofacial Apraxia was quantified also by a specific camera, with an appropriately developed software, able to detect the range of motion of automatic face movements and the range of the same movements on voluntary requests. In order to improve voluntary movements, the participant completed fifteen 1-hour rehabilitation sessions, composed of a 20-minutes immersive Action Observation Therapy followed by a 40-minutes Virtual Reality Augmented Feedback sessions, 5 days a week, for 3 consecutive weeks.

Results:

After treatment, participant achieved great improvements in quality and range of facial movements, performing most of the facial expressions (eg, kiss, smile, lateral angle of mouth displacement) without unsolicited movement. Furthermore, the Upper and Lower Face Apraxia Test showed an improvement of 118% for the Upper Face movements and of 200% for the Lower Face movements.

Conclusion:

Performing voluntary movement in a Virtual Reality environment with Augmented Feedbacks, in addition to Action Observation Therapy, improved performances of facial gestures and consolidate the activations by the central nervous system based on principles of experience-dependent neural plasticity.

Clinical Application of Virtual Reality for Upper Limb Motor Rehabilitation in Stroke: Review of Technologies and Clinical Evidence

Neurorehabilitation for stroke is important for upper limb motor recovery. Conventional rehabilitation such as occupational therapy has been used, but novel technologies are expected to open new opportunities for better recovery. Virtual reality (VR) is a technology with a set of informatics that provides interactive environments to patients. VR can enhance neuroplasticity and recovery after a stroke by providing more intensive, repetitive, and engaging training due to several advantages, including: (1) tasks with various difficulty levels for rehabilitation, (2) augmented real-time feedback, (3) more immersive and engaging experiences, (4) more standardized rehabilitation, and (5) safe simulation of real-world activities of daily living. In this comprehensive narrative review of the application of VR in motor rehabilitation after stroke, mainly for the upper limbs, we cover: (1) the technologies used in VR rehabilitation, including sensors; (2) the clinical application of and evidence for VR in stroke rehabilitation; and (3) considerations for VR application in stroke rehabilitation. Meta-analyses for upper limb VR rehabilitation after stroke were identified by an online search of Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Library, and KoreaMed. We expect that this review will provide insights into successful clinical applications or trials of VR for motor rehabilitation after stroke.