Virtual reality therapy for upper limb rehabilitation in patients with stroke: a meta-analysis of randomized clinical trials

The impact of simulation-based training in medical education: A review

Simulation-based training (SBT) has emerged as a transformative approach in medical education, significantly enhancing healthcare professionals' learning experience and clinical competency. This article explores the impact of SBT, tracing its historical development and examining the various types of simulations utilized today, including high-fidelity mannequins, virtual reality environments, standardized patients, and hybrid simulations. These methods offer a safe and controlled environment for students to practice and hone technical and non-technical skills, ultimately improving patient safety and clinical outcomes. The benefits of SBT are manifold, including enhanced skill acquisition, error reduction, and the opportunity for repeated practice without risk to actual patients. Immediate feedback and structured debriefing further solidify learning, making Simulation an invaluable tool in medical education. However, the implementation of SBT is challenging. It requires substantial financial investment, specialized equipment, and trained faculty. Additionally, there are concerns about the realism of simulations and the transferability of skills to real-world clinical settings. Despite these challenges, numerous case studies and empirical research underscore the effectiveness of SBT compared to traditional methods. Looking ahead, advancements in technology, such as artificial intelligence and improved virtual reality applications, promise to enhance the efficacy and accessibility of simulation training. The integration of Simulation with other training modalities and its adoption in diverse global contexts highlight its potential to revolutionize medical education worldwide. This article affirms the crucial role of SBT in preparing the next generation of healthcare professionals and its ongoing evolution driven by technological innovations.

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 ].

Haptic Feedback, Performance and Arousal: A Comparison Study in an Immersive VR Motor Skill Training Task

This article investigates the relationship between fine motor skill training in VR, haptic feedback, and physiological arousal. To do so, we present the design and development of a motor skill task (buzzwire), along with a custom vibrotactile feedback attachment for the Geomagic Touch haptic device. A controlled experiment following a between-subjects design was conducted with 73 participants, studying the role of three feedback conditions - visual/kinesthetic, visual/vibrotactile and visual only - on the learning and performance of the considered task and the arousal levels of the participants. Results indicate that performance improved in all three feedback conditions after the considered training session. However, participants reported no change in self-efficacy and in terms of presence and task load (NASA-TLX). All three feedback conditions also showed similar arousal levels. Further analysis revealed that positive changes in performance were linked to higher arousal levels. These results suggest the potential of haptic feedback to affect arousal levels and encourage further research into using this relationship to improve motor skill training in VR.

Performance-based outcome measures of upper extremity in virtual reality and telerehabilitation: a systematic review

OBJECTIVES

This systematic review aimed to identify and synthesize evidence regarding measurement properties of upper extremity performance-based outcome measures performed in virtual reality or in telerehabilitation to inform clinical applications and research endeavors.

METHODS

Five bibliographic databases, PubMed, Embase, CINAHL, APA PsycINFO, and Scopus, were searched on July 12, 2023. Studies assessing the measurement properties (reliability, validity, responsiveness) of upper extremity performance-based outcome measures in virtual reality and telerehabilitation were eligible for inclusion. The COSMIN risk of bias checklist was used for methodological quality assessment. Study selection, data extraction, and quality assessment were completed by two independent reviewers.

RESULTS

A total of 240 records were identified from the five databases. Nine cross-sectional studies published from 2016 to 2023 were included. Participants included 210 patients with neurological conditions and 184 healthy subjects. In virtual reality studies, four implemented the Box and Block Test, one the Arm Research Action Test, and one the Peg Insertion Test. In telerehabilitation studies, three implemented the Fugl-Meyer Assessment Upper Extremity. For quality assessment, one study was rated inadequate, one was rated doubtful, and all others demonstrated adequate to good quality. Most studies demonstrated good test-retest reliability and concurrent validity to the original in-person assessments.

CONCLUSION

Implementing upper extremity performance-based outcome measures in virtual reality and telerehabilitation is feasible and promising. Further studies are warranted to develop and refine remote assessment paradigms and validate them on a larger scale to inform clinical application and promote digital health in rehabilitation.

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.

Evaluating the Accuracy of Upper Limb Movement in the Sagittal Plane among Computer Users during the COVID-19 Pandemic

(1) Background: The most common musculoskeletal pathology among healthcare professionals is neck and/or shoulder pain. The aim of this study was to determine the dominant upper limb functionality concerning the ability to replicate a given movement pattern among employees reporting neck or upper limb pain while using a computer during the COVID-19 pandemic. (2) Methods: The study was conducted from March to April 2021 on a group of 45 medical employees who used a computer workstation for 4 to 6 h of their working time. In the design of this study, three study groups were created: a group of patients with pain syndrome of segment C5/C7 of the spine, a group of patients with shoulder pain syndrome, and a control group of healthy volunteers. (3) Results: The examined groups significantly differed in the correctness of performing the given movement (p = 0.001) and the minimum value of inclination during the exercise session (p = 0.026), as well as the maximum lowering (p = 0.03) in relation to the control group. (4) Conclusions: The VECTIS device can be used to assess the accuracy of reflecting the prescribed movement of the upper limb in rehabilitation programs for patients with cervical spine pain syndrome and shoulder pain syndrome.

Do digital health interventions hold promise for stroke prevention and care in Black and Latinx populations in the United States? A scoping review

BACKGROUND

Black and Latinx populations are disproportionately affected by stroke and are likely to experience gaps in health care. Within fragmented care systems, remote digital solutions hold promise in reversing this pattern. However, there is a digital divide that follows historical disparities in health. Without deliberate attempts to address this digital divide, rapid advances in digital health will only perpetuate systemic biases. This study aimed to characterize the range of digital health interventions for stroke care, summarize their efficacy, and examine the inclusion of Black and Latinx populations in the evidence base.

METHODS

We searched PubMed, the Web of Science, and EMBASE for publications between 2015 and 2021. Inclusion criteria include peer-reviewed systematic reviews or meta-analyses of experimental studies focusing on the impact of digital health interventions on stroke risk factors and outcomes in adults. Detailed information was extracted on intervention modality and functionality, clinical/behavioral outcome, study location, sample demographics, and intervention results.

RESULTS

Thirty-eight systematic reviews met inclusion criteria and yielded 519 individual studies. We identified six functional categories and eight digital health modalities. Case management (63%) and health monitoring (50%) were the most common intervention functionalities. Mobile apps and web-based interventions were the two most commonly studied modalities. Evidence of efficacy was strongest for web-based, text-messaging, and phone-based approaches. Although mobile applications have been widely studied, the evidence on efficacy is mixed. Blood pressure and medication adherence were the most commonly studied outcomes. However, evidence on the efficacy of the various intervention modalities on these outcomes was variable. Among all individual studies, only 38.0% were conducted in the United States (n = 197). Of these U.S. studies, 54.8% adequately reported racial or ethnic group distribution. On average, samples were 27.0% Black, 17.1% Latinx, and 63.4% White.

CONCLUSION

While evidence of the efficacy of selected digital health interventions, particularly those designed to improve blood pressure management and medication adherence, show promise, evidence of how these interventions can be generalized to historically underrepresented groups is insufficient. Including these underrepresented populations in both digital health experimental and feasibility studies is critical to advancing digital health science and achieving health equity.

Sensorimotor rhythm and muscle activity in patients with stroke using mobile serious games to assist upper extremity rehabilitation

Introduction

Exercise rehabilitation is crucial for neurological recovery in hemiplegia-induced upper limb dysfunction. Technology-assisted cortical activation in sensorimotor areas has shown potential for restoring motor function. This study assessed the feasibility of mobile serious games for stroke patients' motor rehabilitation.

Methods

A dedicated mobile application targeted shoulder, elbow, and wrist training. Twelve stroke survivors attempted a motor task under two conditions: serious mobile game-assisted and conventional rehabilitation. Electroencephalography and electromyography measured the therapy effects.

Results

Patients undergoing game-assisted rehabilitation showed stronger event-related desynchronization (ERD) in the contralateral hemisphere's motor perception areas compared to conventional rehabilitation (p < 0.05). RMS was notably higher in game-assisted rehabilitation, particularly in shoulder training (p < 0.05).

Discussion

Serious mobile game rehabilitation activated the motor cortex without directly improving muscle activity. This suggests its potential in neurological recovery for stroke patients.

The use of virtual reality in the rehabilitation of aphasia: a systematic review

PURPOSE

This systematic review explored how virtual reality (VR) has been used to rehabilitate aphasia.

MATERIALS AND METHODS

Empirical studies were included where VR was used to target language, well-being, or quality of life in adults with acquired language impairment. Degenerative communication disabilities were excluded. Seven health databases were searched in October 2021. Risk of Bias was assessed using published checklists and completeness of intervention reporting evaluated. Narrative synthesis described forms of VR, rationales given, outcome measures, communication functions targeted, characteristics of interventions, and outcomes achieved within the framework of impairment, activity, and participation.

RESULTS

Fourteen studies, involving 229 participants, met the criteria. The studies employed four forms of VR with various rationales given. Interventions used published and novel protocols. Primary outcomes targeted language impairment (12/14), activity (1/14), and well-being (1/14) and achieved positive outcomes in impairment and activity. All studies were exploratory. Risk of bias was high. Findings are discussed in the context of gains achieved by VR in other health contexts and the multi-user gaming literature.

CONCLUSIONS

Uses of VR in aphasia rehabilitation described in the literature are limited. Most applications target the remediation of language impairments. Opportunities to address activity, participation, and wider aspects of well-being are rare.IMPLICATIONS FOR REHABILITATIONResearch documenting the use of virtual reality (VR) to rehabilitate aphasia is limited and exploratory, so does not yet offer clear guidance for clinicians.Many of the identified studies have used known published protocols (e.g., naming therapy or scripts therapy) delivered through the novel VR format and focus on language impairment outcomes.VR offers clinicians a unique opportunity to address communication activity and participation through the use of multi-user virtual worlds, but this has only been explored by only two research teams.

A Comparison of Immersive vs. Non-Immersive Virtual Reality Exercises for the Upper Limb: A Functional Near-Infrared Spectroscopy Pilot Study with Healthy Participants

Functional near-infrared spectroscopy (fNIRS) allows for a reliable assessment of oxygenated blood flow in relevant brain regions. Recent advancements in immersive virtual reality (VR)-based technology have generated many new possibilities for its application, such as in stroke rehabilitation. In this study, we asked whether there is a difference in oxygenated hemoglobin (HbO2) within brain motor areas during hand/arm movements between immersive and non-immersive VR settings. Ten healthy young participants (24.3 ± 3.7, three females) were tested using a specially developed VR paradigm, called "bus riding", whereby participants used their hand to steer a moving bus. Both immersive and non-immersive conditions stimulated brain regions controlling hand movements, namely motor cortex, but no significant differences in HbO2 could be found between the two conditions in any of the relevant brain regions. These results are to be interpreted with caution, as only ten participants were included in the study.

A diagnostic room for lower limb amputee based on virtual reality and an intelligent space

This article proposes a virtual reality (VR) system for diagnosing and rehabilitating lower limb amputees. A virtual environment and an intelligent space are the basis of the proposed solution. The target audiences are physiotherapists and doctors, and the aim is to provide a VR-based system to allow visualization and analysis of gait parameters and conformity. The multi-camera system from the intelligent space acquires images from patients during gait. This way, it is possible to generate tridimensional information for the VR-based system. Among the provided functionalities, the user can explore the virtual environment and manage several features, such as gait reproduction and parameters displayed, using a head-mounted display and hand controllers. Besides, the system presents an automatic classifier that can assist physiotherapists and doctors in assessing abnormalities from conventional human gait. We evaluate the system through two quantitative experiments. The first one addresses the performance evaluation of the automatic classifier. The second analysis is through a Likert scale questionnaire submitted to a group of physiotherapists. In this case, the specialists evaluate the existing features of the proposed framework. The results from the questionnaire showed that the virtual environment is suitable for helping track patients' rehabilitation. Also, the neural network-based classifier results are promising, averaging higher than 91% for all evaluation metrics. Finally, a comparison with related works in the literature highlights the contributions of the proposed solution to the field.

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.

Effects of Virtual Reality on the Limb Motor Function, Balance, Gait, and Daily Function of Patients with Stroke: Systematic Review

Background and Objectives: This systematic review aimed to clarify the effectiveness of virtual reality rehabilitation on physical outcomes for people with stroke. Materials and Methods: Articles were searched through PubMed, EMBASE, the Cochrane Library, the Physiotherapy Evidence Database, CINAHL, Web of Science, and ProQuest Dissertations and Theses, from inception to 30 April 2022. Methodological quality was scored using the Assessing the Methodological Quality of Systematic Reviews 2 tool. Each systematic review for the outcome of interest was assessed by two independent reviewers using the Grading of Recommendations Assessment, Development, and Evaluation system. Results: Twenty-six articles were selected. These studies evaluated the effectiveness of virtual reality on limb motor function, balance, gait, and daily function in patients with stroke. The findings suggested a beneficial effect of virtual reality; there was a "very low" to "moderate" quality of evidence for improved limb extremity function, balance, and daily function, and a "very low" to "moderate" quality of evidence for improved gait. Conclusions: Despite widespread interest in the use of virtual reality rehabilitation, high-quality evidence for its routine use in stroke treatment is lacking. Further research is needed to determine the treatment modality, duration, and long-term effects of virtual reality on stroke populations.

Post-Stroke Rehabilitation of Distal Upper Limb with New Perspective Technologies: Virtual Reality and Repetitive Transcranial Magnetic Stimulation-A Mini Review

Upper extremity motor impairment is the most common sequelae in patients with stroke. Moreover, its continual nature limits the optimal functioning of patients in the activities of daily living. Because of the intrinsic limitations in the conventional form of rehabilitation, the rehabilitation applications have been expanded to technology-driven solutions, such as Virtual Reality and Repetitive Transcranial Magnetic Stimulation (rTMS). The motor relearning processes are influenced by variables, such as task specificity, motivation, and feedback provision, and a VR environment in the form of interactive games could provide novel and motivating customized training solutions for better post-stroke upper limb motor improvement. rTMS being a precise non-invasive brain stimulation method with good control of stimulation parameters, has the potential to facilitate neuroplasticity and hence a good recovery. Although several studies have discussed these forms of approaches and their underlying mechanisms, only a few of them have specifically summarized the synergistic applications of these paradigms. To bridge the gaps, this mini review presents recent research and focuses precisely on the applications of VR and rTMS in distal upper limb rehabilitation. It is anticipated that this article will provide a better representation of the role of VR and rTMS in distal joint upper limb rehabilitation in patients with stroke.

Can specific virtual reality combined with conventional rehabilitation improve poststroke hand motor function? A randomized clinical trial

TRIAL OBJECTIVE

To verify whether conventional rehabilitation combined with specific virtual reality is more effective than conventional therapy alone in restoring hand motor function and muscle tone after stroke.

TRIAL DESIGN

This prospective single-blind randomized controlled trial compared conventional rehabilitation based on physiotherapy and occupational therapy (control group) with the combination of conventional rehabilitation and specific virtual reality technology (experimental group). Participants were allocated to these groups in a ratio of 1:1. The conventional rehabilitation therapists were blinded to the study, but neither the participants nor the therapist who applied the virtual reality-based therapy could be blinded to the intervention.

PARTICIPANTS

Forty-six patients (43 of whom completed the intervention period and follow-up evaluation) were recruited from the Neurology and Rehabilitation units of the Hospital General Universitario of Talavera de la Reina, Spain.

INTERVENTION

Each participant completed 15 treatment sessions lasting 150 min/session; the sessions took place five consecutive days/week over the course of three weeks. The experimental group received conventional upper-limb strength and motor training (100 min/session) combined with specific virtual reality technology devices (50 min/session); the control group received only conventional training (150 min/session).

RESULTS

As measured by the Ashworth Scale, a decrease in wrist muscle tone was observed in both groups (control and experimental), with a notably larger decrease in the experimental group (baseline mean/postintervention mean: 1.22/0.39; difference between baseline and follow-up: 0.78; 95% confidence interval: 0.38-1.18; effect size = 0.206). Fugl-Meyer Assessment scores were observed to increase in both groups, with a notably larger increase in the experimental group (total motor function: effect size = 0.300; mean: - 35.5; 95% confidence interval: - 38.9 to - 32.0; wrist: effect size = 0.290; mean: - 5.6; 95% confidence interval: - 6.4 to - 4.8; hand: effect size = 0.299; mean: - -8.9; 95% confidence interval: - 10.1 to - 7.6). On the Action Research Arm Test, the experimental group quadrupled its score after the combined intervention (effect size = 0.321; mean: - 32.8; 95% confidence interval: - 40.1 to - 25.5).

CONCLUSION

The outcomes of the study suggest that conventional rehabilitation combined with a specific virtual reality technology system can be more effective than conventional programs alone in improving hand motor function and voluntary movement and in normalizing muscle tone in subacute stroke patients. With combined treatment, hand and wrist functionality and motion increase; resistance to movement (spasticity) decreases and remains at a reduced level.

TRIALS REGISTRY

International Clinical Trials Registry Platform: ISRCTN27760662 (15/06/2020; retrospectively registered).

Comparison of immersive and non-immersive virtual reality for upper extremity functional recovery in patients with stroke: a systematic review and network meta-analysis

OBJECTIVE

This systematic review aimed to compare the effects of immersive and non-immersive virtual reality on upper extremity function in stroke survivors by employing a network meta-analysis approach.

DATA SOURCES

MEDLINE, Embase, CINAHL Plus, APA PsycINFO, and Scopus were searched. Virtual reality was used for upper extremity rehabilitation; dose-matched conventional rehabilitation was used for comparison. Fugl-Meyer Assessment was used to assess upper extremity function. Searches were limited to English language randomized controlled trials.

METHODS

Two independent reviewers conducted study selection, data extraction, and quality assessment. Methodological quality was assessed using the Physiotherapy Evidence Database scale. A random-effects frequentist network meta-analysis was conducted by assuming a common random-effects standard deviation for all comparisons in the network.

RESULTS

Twenty randomized controlled trials with 813 participants were included, with each study evaluated as good quality. Immersive virtual reality systems were most effective at improving upper extremity function, followed by non-immersive virtual reality systems, then non-immersive gaming consoles of Microsoft Kinect and Nintendo Wii. Conventional rehabilitation was least effective. Immersive virtual reality was estimated to induce 1.39 (95% confidence interval (CI): 0.25, 2.53) and 1.38 (95% CI: 0.55, 2.20) standard mean differences of improvements in upper extremity function, compared to Nintendo Wii intervention and conventional rehabilitation, respectively.

CONCLUSION

This systematic review and network meta-analysis highlights the superior effects of immersive virtual reality to non-immersive virtual reality systems and gaming consoles on upper extremity motor recovery.

Virtual reality for public health: a study on a VR intervention to enhance occupational injury prevention

BACKGROUND

Agriculture is one of the most hazardous occupations in the USA. Especially, tractor rollover incidents are the leading cause of farming-related injuries or deaths. This study examines the effect of a VR intervention (Virtual Reality Intervention for Safety Education; VRISE) on behavioral intentions for occupational safety and identifies a psychological mechanism that shows how the immersive technology works.

METHODS

VRISE was developed by a multidisciplinary team of agricultural educators, computer scientists and communication specialists. It was designed to provide a virtual environment where users practice tractor operation and try to avoid several rollover hazards. The participants (291 high school students) were recruited at the 2019 National Future Farmers Association Convention & Expo and randomly assigned to one of three conditions: two different types of control groups (Control1: No treatment group and Control2: 2D Screen group) and the treatment group.

RESULTS

Findings show that, through the immersive VR experience, the VR intervention enhanced perceived threat of tractor-related accidents which in turn, led to improved behavioral intentions for tractor safety.

CONCLUSIONS

Findings shed light on the effectiveness of a VR intervention to improve public health outcomes, especially in occupational safety education, where unsafe practices often result in injury and fatality.

How Do Motor and Sensory Function Correlate with Daily Performance Recovery after Post-Stroke Robotic Intervention? A Secondary Analysis of a Non-Randomized Controlled Trial

New technologies have been developed to complement conventional interventions to better target the specific needs of people with stroke, and they have been shown to improve both function and performance. However, it is unknown whether the baseline levels of sensorimotor function and performance interrelate with the improvement in upper limb and daily performance. Thus, the aim of this study was to examine the relationship between baseline levels of sensorimotor function and daily performance and its impact on post-intervention improvement in people with stroke following a robotic intervention. A single-blind, non-randomized, controlled clinical trial was conducted. Participants in the experimental group (n = 9) received a robotic intervention in addition to conventional treatment. Sensorimotor function was measured with Semmes-Weinstein Monofilaments® and the Fugl-Meyer Assessment Upper Extremity Scale. Upper limb and daily performance were measured with the MAL and SIS-16 scales. The multivariate regression models showed that baseline levels of upper limb performance and motor function predicted >95% of the variance in upper limb performance (p < 0.001), while pre-intervention levels of daily performance explained >75% of the post-intervention variance (p < 0.05). These findings indicate that basal upper limb motor function is associated with improved performance following a combined intervention of conventional treatment and robotic intervention.

A scoping review to assess the effects of virtual reality in medical education and clinical care

Due to the challenges and restrictions posed by COVID-19 pandemic, technology and digital solutions played an important role in the rendering of necessary healthcare services, notably in medical education and clinical care. The aim of this scoping review was to analyze and sum up the most recent developments in Virtual Reality (VR) use for therapeutic care and medical education, with a focus on training medical students and patients. We identified 3743 studies, of which 28 were ultimately selected for the review. The search strategy followed the most recent Preferred Reporting Items for Systematic Reviews and Meta-Analysis for scoping review (PRISMA-ScR) guidelines. 11 studies (39.3%) in the field of medical education assessed different domains, such as knowledge, skills, attitudes, confidence, self-efficacy, and empathy. 17 studies (60.7%) focused on clinical care, particularly in the areas of mental health, and rehabilitation. Among these, 13 studies also investigated user experiences and feasibility in addition to clinical outcomes. Overall, the findings of our review reported considerable improvements in terms of medical education and clinical care. VR systems were also found to be safe, engaging, and beneficial by the studies' participants. There were huge variations in studies with respect to the study designs, VR contents, devices, evaluation methods, and treatment periods. In the future, studies may focus on creating definitive guidelines that can help in improving patient care further. Hence, there is an urgent need for researchers to collaborate with the VR industry and healthcare professionals to foster a better understanding of contents and simulation development.

Immersive virtual reality for improving cognitive deficits in children with ADHD: a systematic review and meta-analysis

Virtual reality (VR) shows great potential in treating and managing various mental health conditions. This includes using VR for training or rehabilitation purposes. For example, VR is being used to improve cognitive functioning (e.g. attention) among children with attention/deficit-hyperactivity disorder (ADHD). The aim of the current review and meta-analysis is to evaluate the effectiveness of immersive VR-based interventions for improving cognitive deficits in children with ADHD, to investigate potential moderators of the effect size and assess treatment adherence and safety. The meta-analysis included seven randomised controlled trials (RCTs) of children with ADHD comparing immersive VR-based interventions with controls (e.g. waiting list, medication, psychotherapy, cognitive training, neurofeedback and hemoencephalographic biofeedback) on measures of cognition. Results indicated large effect sizes in favour of VR-based interventions on outcomes of global cognitive functioning, attention, and memory. Neither intervention length nor participant age moderated the effect size of global cognitive functioning. Control group type (active vs passive control group), ADHD diagnostic status (formal vs. informal) and novelty of VR technology were not significant moderators of the effect size of global cognitive functioning. Treatment adherence was similar across groups and there were no adverse effects. Results should be cautiously interpreted given the poor quality of included studies and small sample.

Virtual Reality for Motor and Cognitive Rehabilitation

Virtual Reality (VR) affords clinicians the ability to deliver safe, controlled, task-specific customised interventions that are enjoyable, motivating and engaging. Elements of training in VR comply with principles of learning implicated in new skill acquisition and re-learning skills post-neurological disorders. However, heterogeneity in the description of VR systems and the description and control of 'active' ingredients of interventions (like dosage, type of feedback, task specificity, etc.) have led to inconsistency in the synthesis and interpretation of evidence related to the effectiveness of VR-based interventions, particularly in post-stroke and Parkinson's Disease (PD) rehabilitation. This chapter attempts to describe VR interventions with respect to their compliance with principles of neurorehabilitation, with the goal of optimising interventions for effective training and facilitation of maximum functional recovery. This chapter also advocates using a uniform framework to describe VR systems to promote homogeneity in literature in order to help in the synthesis of evidence. An overview of the evidence revealed that VR systems are effective in mediating deficits in upper extremity, posture and gait function seen in people post-stroke and PD. Generally, interventions were more effective when they were delivered as an adjunct to conventional therapy and were customised for rehabilitation purposes, in addition to complying with principles of learning and neurorehabilitation. Although recent studies imply that their VR intervention is compliant with principles of learning, only a few explicitly describe how these principles are incorporated as 'active ingredients' of the intervention. Finally, VR interventions targeting community ambulation and cognitive rehabilitation are yet limited and therefore warrant attention.

Effect of immersive visualization technologies on cognitive load, motivation, usability, and embodiment

Virtual reality (VR) is a promising tool to promote motor (re)learning in healthy users and brain-injured patients. However, in current VR-based motor training, movements of the users performed in a three-dimensional space are usually visualized on computer screens, televisions, or projection systems, which lack depth cues (2D screen), and thus, display information using only monocular depth cues. The reduced depth cues and the visuospatial transformation from the movements performed in a three-dimensional space to their two-dimensional indirect visualization on the 2D screen may add cognitive load, reducing VR usability, especially in users suffering from cognitive impairments. These 2D screens might further reduce the learning outcomes if they limit users' motivation and embodiment, factors previously associated with better motor performance. The goal of this study was to evaluate the potential benefits of more immersive technologies using head-mounted displays (HMDs). As a first step towards potential clinical implementation, we ran an experiment with 20 healthy participants who simultaneously performed a 3D motor reaching and a cognitive counting task using: (1) (immersive) VR (IVR) HMD, (2) augmented reality (AR) HMD, and (3) computer screen (2D screen). In a previous analysis, we reported improved movement quality when movements were visualized with IVR than with a 2D screen. Here, we present results from the analysis of questionnaires to evaluate whether the visualization technology impacted users' cognitive load, motivation, technology usability, and embodiment. Reports on cognitive load did not differ across visualization technologies. However, IVR was more motivating and usable than AR and the 2D screen. Both IVR and AR rea ched higher embodiment level than the 2D screen. Our results support our previous finding that IVR HMDs seem to be more suitable than the common 2D screens employed in VR-based therapy when training 3D movements. For AR, it is still unknown whether the absence of benefit over the 2D screen is due to the visualization technology per se or to technical limitations specific to the device.

Effectiveness, safety and patients' perceptions of an immersive virtual reality-based exercise system for poststroke upper limb motor rehabilitation: A proof-of-concept and feasibility randomized controlled trial

Objective

This study aimed to examine the effectiveness, safety and patients' perceptions of an immersive virtual reality (VR)-based exercise system for poststroke upper limb rehabilitation.

Methods

A proof-of-concept, 2-week randomized controlled trial was conducted. Fifty stroke patients were randomly assigned to either use the immersive VR-based exercise system to perform upper limb exercises for 2 weeks (intervention) or play commercial games (control). Effectiveness, safety and patients' perceptions of the exercise system were assessed at baseline and at 1- and 2-week follow-ups.

Results

Intention-to-treat analysis revealed that after 2 weeks, statistically significant improvements in shoulder flexion active range of motion (AROM), shoulder abduction AROM, perceived upper limb motor function and quality of life (QoL) were observed in one or both groups, but not between the groups. Per-protocol analysis showed that after 2 weeks: (i) statistically significant improvement in shoulder abduction AROM was obtained in the intervention group, and the difference in the mean changes between the groups was statistically significant; (ii) statistically significant improvements in coordination/speed (Fugl-Meyer Assessment for Upper Extremity), shoulder flexion AROM, perceived upper limb motor function and QoL were obtained in one or both groups, but not between the groups.

Conclusions

The immersive VR-based exercise system is a potentially effective, safe and acceptable approach for supporting poststroke motor rehabilitation. These findings can serve as a basis for larger-scale studies on the application of VR for poststroke exercises.

Neurodata Tracker: Software for computational assessment of hand motor skills based on optical motion capture in a virtual environment

Objectives

Deficits affecting hand motor skills negatively impact the quality of life of patients. The NeuroData Tracker platform has been developed for the objective and precise evaluation of hand motor deficits. We describe the design and development of the platform and analyse the technological feasibility and usability in a relevant clinical setting.

Methods

A software application was developed in Unity (C#) to obtain kinematic data from hand movement tracking by a portable device with two cameras and three infrared sensors (leap motion®). Four exercises were implemented: (a) wrist flexion-extension (b) finger-grip opening-closing (c) finger spread (d) fist opening-closing. The most representative kinematic parameters were selected for each exercise. A script in Python was integrated in the platform to transform real-time kinematic data into relevant information for the clinician. The application was tested in a pilot study comparing the data provided by the tool from ten healthy subjects without any motor impairment and ten patients diagnosed with a stroke with mild to moderate hand motor deficit.

Results

The NeuroData Tracker allowed the parameterization of kinematics of hand movement and the issuance of a report with the results. The comparison of the data obtained suggests the feasibility of the tool for detecting differences between patients and healthy subjects.

Conclusions

This new platform based on optical motion capturing provides objective measurement of hand movement allowing quantification of motor deficits. These findings require further validation of the tool in larger trials to verify its usefulness in the clinical setting.

Naturalistic visualization of reaching movements using head-mounted displays improves movement quality compared to conventional computer screens and proves high usability

BACKGROUND

The relearning of movements after brain injury can be optimized by providing intensive, meaningful, and motivating training using virtual reality (VR). However, most current solutions use two-dimensional (2D) screens, where patients interact via symbolic representations of their limbs (e.g., a cursor). These 2D screens lack depth cues, potentially deteriorating movement quality and increasing cognitive load. Head-mounted displays (HMDs) have great potential to provide naturalistic movement visualization by incorporating improved depth cues, reduce visuospatial transformations by rendering movements in the space where they are performed, and preserve eye-hand coordination by showing an avatar-with immersive VR (IVR)-or the user's real body-with augmented reality (AR). However, elderly populations might not find these novel technologies usable, hampering potential motor and cognitive benefits.

METHODS

We compared movement quality, cognitive load, motivation, and system usability in twenty elderly participants (>59 years old) while performing a dual motor-cognitive task with different visualization technologies: IVR HMD, AR HMD, and a 2D screen. We evaluated participants' self-reported cognitive load, motivation, and usability using questionnaires. We also conducted a pilot study with five brain-injured patients comparing the visualization technologies while using an assistive device.

RESULTS

Elderly participants performed straighter, shorter duration, and smoother movements when the task was visualized with the HMDs than screen. The IVR HMD led to shorter duration movements than AR. Movement onsets were shorter with IVR than AR, and shorter for both HMDs than the screen, potentially indicating facilitated reaction times due to reduced cognitive load. No differences were found in the questionnaires regarding cognitive load, motivation, or usability between technologies in elderly participants. Both HMDs proved high usability in our small sample of patients.

CONCLUSIONS

HMDs are a promising technology to be incorporated into neurorehabilitation, as their more naturalistic movement visualization improves movement quality compared to conventional screens. HMDs demonstrate high usability, without decreasing participants' motivation, and might potentially lower cognitive load. Our preliminary clinical results suggest that brain-injured patients may especially benefit from more immersive technologies. However, larger patient samples are needed to draw stronger conclusions.*.

Rehabilitation of motor function after stroke: A bibliometric analysis of global research from 2004 to 2022

BACKGROUND AND AIMS

The mortality rate of stroke has been increasing worldwide. Poststroke somatic dysfunctions are common. Motor function rehabilitation of patients with such somatic dysfunctions enhances the quality of life and has long been the primary practice to achieve functional recovery. In this regard, we aimed to delineate the new trends and frontiers in stroke motor function rehabilitation literature published from 2004 to 2022 using a bibliometric software.

METHODS

All documents related to stroke rehabilitation and published from 2004 to 2022 were retrieved from the Web of Science Core Collection. Publication output, research categories, countries/institutions, authors/cocited authors, journals/cocited journals, cocited references, and keywords were assessed using VOSviewer v.1.6.15.0 and CiteSpace version 5.8. The cocitation map was plotted according to the analysis results to intuitively observe the research hotspots.

RESULTS

Overall, 3,302 articles were retrieved from 78 countries or regions and 564 institutions. Over time, the publication outputs increased annually. In terms of national contribution, the United States published the most papers, followed by China, Japan, South Korea, and Canada. Yeungnam University had the most articles among all institutions, followed by Emory University, Fudan University, and National Taiwan University. Jang Sung Ho and Wolf S.L. were the most productive (56 published articles) and influential (cited 1,121 times) authors, respectively. "Effect of constraint-induced movement therapy on upper extremity function 3-9 months after stroke: the Extremity Constraint Induced Therapy Evaluation randomized clinical trial" was the most frequently cited reference. Analysis of keywords showed that upper limbs, Fugl-Meyer assessment, electromyography, virtual reality, telerehabilitation, exoskeleton, and brain-computer interface were the research development trends and focus areas for this topic.

CONCLUSION

Publications regarding motor function rehabilitation following stroke are likely to continuously increase. Research on virtual reality, telemedicine, electroacupuncture, the brain-computer interface, and rehabilitation robots has attracted increasing attention, with these topics becoming the hotspots of present research and the trends of future research.

Analysis of Rehabilitation Occupational Therapy Techniques Based on Instrumental Music Chinese Tonal Language Spectrogram Analysis

This paper provides an in-depth analysis of timbre-speech spectrograms in instrumental music, designs a model analysis of rehabilitation occupational therapy techniques based on the analysis of timbre-speech spectrograms in instrumental music, and tests the models for comparison. Starting from the mechanism of human articulation, this paper models the process of human expression as a time-varying linear system consisting of excitation, vocal tract, and radiation models. The system's overall architecture is designed according to the characteristics of Chinese speech and everyday speech rehabilitation theory (HSL theory). The dual judgment of temporal threshold and short-time average energy realized the phonetic length training. Tone and clear tone training were achieved by linear predictive coding technique (LPC) and autocorrelation function. Using the DTW technique, isolated word speech recognition was achieved by extracting Mel-scale Frequency Cepstral Coefficients (MFCC) parameters of speech signals. The system designs corresponding training scenes for each training module according to the extracted speech parameters, combines the multimedia speech spectrogram motion situation with the speech parameters, and finally presents the training content as a speech spectrogram, and evaluates the training results through human-machine interaction to stimulate the interest of rehabilitation therapy and realize the speech rehabilitation training of patients. After analyzing the pre- and post-test data, it was found that the p-values of all three groups were <0.05, which was judged to be significantly different. Also, all subjects changed their behavioral data during the treatment. Therefore, it was concluded that the music therapy technique could improve the patients' active gaze communication ability, verbal command ability, and active question-answering ability after summarizing the data, i.e., the hypothesis of this experiment is valid. Therefore, it is believed that the technique of timbre-speech spectrogram analysis in instrumental music can achieve the effect of rehabilitation therapy to a certain extent.

A novel immersive virtual reality environment for the motor rehabilitation of stroke patients: A feasibility study

We designed and implemented an immersive virtual reality (VR) environment for upper limb rehabilitation, which possesses several notable features. First, by exploiting modern computer graphics its can present a variety of scenarios that make the rehabilitation routines challenging yet enjoyable for patients, thus enhancing their adherence to the therapy. Second, immersion in a virtual 3D space allows the patients to execute tasks that are closely related to everyday gestures, thus enhancing the transfer of the acquired motor skills to real-life routines. Third, in addition to the VR environment, we also developed a client app running on a PC that allows to monitor in real-time and remotely the patients’ routines thus paving the way for telerehabilitation scenarios. Here, we report the results of a feasibility study in a cohort of 16 stroke patients. All our patients showed a high degree of comfort in our immersive VR system and they reported very high scores of ownership and agency in embodiment and satisfaction questionnaires. Furthermore, and notably, we found that behavioral performances in our VR tasks correlated with the patients’ clinical scores (Fugl-Meyer scale) and they could thus be used to assess improvements during the rehabilitation program. While further studies are needed, our results clearly support the feasibility and effectiveness of VR-based motor rehabilitation processes.

Examining the effectiveness of virtual, augmented, and mixed reality (VAMR) therapy for upper limb recovery and activities of daily living in stroke patients: a systematic review and meta-analysis

INTRODUCTION

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) are emerging technologies in the field of stroke rehabilitation that have the potential to overcome the limitations of conventional treatment. Enhancing upper limb (UL) function is critical in stroke impairments because the upper limb is involved in the majority of activities of daily living (ADL).

METHODS

This study reviewed the use of virtual, augmented and mixed reality (VAMR) methods for improving UL recovery and ADL, and compared the effectiveness of VAMR treatment to conventional rehabilitation therapy. The databases ScienceDirect, PubMed, IEEE Xplore, and Web of Science were examined, and 50 randomized control trials comparing VAMR treatment to standard therapy were determined. The random effect model and fixed effect model are applied based on heterogeneity.

RESULTS

The most often used outcomes of UL recovery and ADL in stroke rehabilitation were the Fugl-Meyer Assessment for Upper Extremities (FMA-UE), followed by the Box and Block Test (BBT), the Wolf Motor Function Test (WMFT), and the Functional Independence Measure (FIM). According to the meta-analysis, VR, AR, and MR all have a significant positive effect on improving FMA-UE for UL impairment (36 studies, MD = 3.91, 95 percent CI = 1.70-6.12, P = 0.0005) and FIM for ADL (10 studies, MD = 4.25, 95 percent CI = 1.47-7.03, P = 0.003), but not on BBT and WMFT for the UL function tests (16 studies, MD = 2.07, 95 percent CI = - 0.58-4.72, P = 0.13), CONCLUSIONS: VAMR therapy was superior to conventional treatment in UL impairment and daily function outcomes, but not UL function measures. Future studies might include further high-quality trials examining the effect of VR, AR, and MR on UL function measures, with an emphasis on subgroup meta-analysis by stroke type and recovery stage.

Measured and Perceived Effects of Upper Limb Home-Based Exergaming Interventions on Activity after Stroke: A Systematic Review and Meta-Analysis

After discharge from the hospital to home, stroke patients may experience weakness and reduced movement in their hemiparetic arms that limits their ability to perform daily activities. Therapists can use exercise games (exergames) to maintain functional abilities and daily use of the arm at home. A systematic review and meta-analysis was conducted to determine the efficiency of upper limb home-based rehabilitation, using exergaming on activity abilities in stroke.&amp;nbsp;Randomized controlled trials were reviewed in the CENTRAL, MEDLINE, CINAHL, EMBASE, and SCOPUS online databases. Clinical measures of observation and self-reporting were studied in post-intervention and follow-up. Nine studies were included in this systematic review (535 participants). The Physiotherapy Evidence Database (PEDro) score was 6.6/10 (SD 1.0, range 5-8), indicating good quality. This systematic review and meta-analysis showed that upper limb home-based exergaming interventions were no more effective in terms of activity than conventional therapy after stroke, according to the observational and subjective assessments in post-intervention and follow-up. Using this same approach, future studies should focus on evaluating home-based exergames through subgroup analysis to be able to propose recommendations.

Effects of Intensive Vibratory Treatment with a Robotic System on the Recovery of Sensation and Function in Patients with Subacute and Chronic Stroke: A Non-Randomized Clinical Trial

Background: Sensory–motor deficits are frequent and affect the functionality after stroke. The use of robotic systems to improve functionality and motor performance is advisable; therefore, the aim of the present study was to evaluate the effects of intensive, high-frequency vibration treatment administered with a robotic system in subacute and chronic stroke patients in terms of upper limb sensitivity, motor function, quantity and quality of movement, and quality of life. Methods: A simple-blind, non-randomized controlled trial was conducted. The control group received conventional rehabilitation treatment and the experimental group received robotic treatment with an Amadeo^® robot in addition to their conventional rehabilitation sessions. Results: Intragroup analysis identified significant improvements in the experimental group in hand (p = 0.012), arm (p = 0.018), and shoulder (p = 0.027) sensitivity, as well as in motor function (FMA-UEmotor function, p = 0.028), integration of the affected limb (MAL-14amount scale, p = 0.011; MAL-14How well scale, p = 0.008), and perceived quality of life (SIS-16, p = 0.008). The measures between the control and experimental groups showed statistically significant differences in motor performance and spontaneous use of the affected limb (MAL-14amount scale, p = 0.021; MAL-14How well scale, p = 0.037). Conclusions: Intensive, high-frequency vibration with a robotic system, in combination with conventional intervention, improves the recovery of upper limb function in terms of quantity and quality of movement in patients with subacute and chronic stroke.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

Biomechanical Assessment of Post-Stroke Patients' Upper Limb before and after Rehabilitation Therapy Based on FES and VR

Stroke is a medical condition characterized by the rapid loss of focal brain function. Post-stroke patients attend rehabilitation training to prevent the degeneration of physical function and improve upper limb movements and functional status after stroke. Promising rehabilitation therapies include functional electrical stimulation (FES), exergaming, and virtual reality (VR). This work presents a biomechanical assessment of 13 post-stroke patients with hemiparesis before and after rehabilitation therapy for two months with these three methods. Patients performed two tests (Maximum Forward Reach and Apley Scratching) where maximum angles, range of motion, angular velocities, and execution times were measured. A Wilcoxon test was performed (p = 0.05) to compare the variables before and after the therapy for paretic and non-paretic limbs. Significant differences were found in range of motion in flexion–extension, adduction–abduction, and internal–external rotation of the shoulder. Increases were found in flexion–extension, 17.98%, and internal–external rotation, 18.12%, after therapy in the Maximum Forward Reach Test. For shoulder adduction–abduction, the increase found was 20.23% in the Apley Scratching Test, supporting the benefits of rehabilitation therapy that combines FES, exergaming, and VR in the literature.

Functional Integration of Mirror Neuron System and Sensorimotor Cortex under Virtual Self-Actions Visual Perception

Virtual reality (VR) technology, with the advantage of immersive visual experience, has been increasingly applied in the rehabilitation therapy of motor deficits. The functional integration of the mirror neuron system and the sensorimotor cortex under the visual perception of actions is one of the theoretical bases for the application of action observation in the neurorehabilitation of motor deficits. Whether the visual experience changes brought by VR technology can further promote this functional integration to be further confirmed. Using the exact low-resolution brain electromagnetic tomography (eLORETA) source localization method, we calculated and statistically tested the whole brain cortical voxel current density estimation under the Electroencephalogram (EEG) signals collected during action observation under the first-person and third-person perspectives in the VR scene for twenty healthy adults. Furthermore, the functional connectivity between the mirror neuron system and the sensorimotor cortex was analyzed using the lagged phase synchronization method. Under the first-person perspective in the VR scene, the current density changes of the core cortices of the mirror neuron system lead to a larger average event-related potential, more significant suppression in the α1 and α2 frequency bands of EEG signals, and a significant enhancement of functional connectivity between the core cortices of the mirror neuron system and the sensorimotor cortex. These findings indicate that compared with the traditional action observation, the visual reappearance of self-actions in the VR scene further stimulates the activity of the core cortices of the mirror neuron system, and promotes the functional integration of the core cortices of the mirror neuron system and the sensorimotor cortex.

Virtual Reality Aided Therapy towards Health 4.0: A Two-Decade Bibliometric Analysis

Health 4.0 aligns with Industry 4.0 and encourages the application of the latest technologies to healthcare. Virtual reality (VR) is a potentially significant component of the Health 4.0 vision. Though VR in health care is a popular topic, there is little knowledge of VR-aided therapy from a macro perspective. Therefore, this paper was aimed to explore the research of VR in aiding therapy, thus providing a potential guideline for futures application of therapeutic VR in healthcare towards Health 4.0. A mixed research method was adopted for this research, which comprised the use of a bibliometric analysis (a quantitative method) to conduct a macro overview of VR-aided therapy, the identification of significant research structures and topics, and a qualitative review of the literature to reveal deeper insights. Four major research areas of VR-aided therapy were identified and investigated, i.e., post-traumatic stress disorder (PTSD), anxiety and fear related disorder (A&F), diseases of the nervous system (DNS), and pain management, including related medical conditions, therapies, methods, and outcomes. This study is the first to use VOSviewer, a commonly used software tool for constructing and visualizing bibliometric networks and developed by Center for Science and Technology Studies, Leiden University, the Netherlands, to conduct bibliometric analyses on VR-aided therapy from the perspective of Web of Science core collection (WoSc), which objectively and visually shows research structures and topics, therefore offering instructive insights for health care stakeholders (particularly researchers and service providers) such as including integrating more innovative therapies, emphasizing psychological benefits, using game elements, and introducing design research. The results of this paper facilitate with achieving the vision of Health 4.0 and illustrating a two-decade (2000 to year 2020) map of pre-life of the Health Metaverse.

Hiding Assistive Robots During Training in Immersive VR Does not Affect Users' Motivation, Presence, Embodiment, Performance, nor Visual Attention

Combining immersive virtual reality (VR) using head-mounted displays (HMDs) with assisting robotic devices might be a promising procedure to enhance neurorehabilitation. However, it is still an open question how immersive virtual environments (VE) should be designed when interacting with rehabilitation robots. In conventional training, the robot is usually not visually represented in the VE, resulting in a visuo-haptic sensory conflict between what users see and feel. This study aimed to investigate how motivation, embodiment, and presence are affected by this visuo-haptic sensory conflict. Using an HMD and a rehabilitation robot, 28 healthy participants performed a path-tracing task, while the robot was either visually reproduced in the VE or not and while the robot either assisted the movements or not. Participants' performance and visual attention were measured during the tasks, and after each visibility/assistance condition, they reported their motivation, presence, and embodiment with questionnaires. We found that, independently of the assistance, the robot visibility did not affect participants' motivation, presence, embodiment, nor task performance. We only found a greater effort/importance reported when the robot was visible. The visual attention was also slightly affected by the robot's visibility. Importantly, we found that the robotic assistance hampered presence and embodiment, but improved motivation. Our results indicate no disadvantage of not reproducing robotic devices in VEs when using HMDs. However, caution must be put when developing assisting controllers, as they might hamper users' affect.

Effects of virtual reality-based motor control training on inflammation, oxidative stress, neuroplasticity and upper limb motor function in patients with chronic stroke: a randomized controlled trial

BACKGROUND

Immersive virtual reality (VR)-based motor control training (VRT) is an innovative approach to improve motor function in patients with stroke. Currently, outcome measures for immersive VRT mainly focus on motor function. However, serum biomarkers help detect precise and subtle physiological changes. Therefore, this study aimed to identify the effects of immersive VRT on inflammation, oxidative stress, neuroplasticity and upper limb motor function in stroke patients.

METHODS

Thirty patients with chronic stroke were randomized to the VRT or conventional occupational therapy (COT) groups. Serum biomarkers including interleukin 6 (IL-6), intracellular adhesion molecule 1 (ICAM-1), heme oxygenase 1 (HO-1), 8-hydroxy-2-deoxyguanosine (8-OHdG), and brain-derived neurotrophic factor (BDNF) were assessed to reflect inflammation, oxidative stress and neuroplasticity. Clinical assessments including active range of motion of the upper limb and the Fugl-Meyer Assessment for upper extremity (FMA-UE) were also used. Two-way mixed analyses of variance (ANOVAs) were used to examine the effects of the intervention (VRT and COT) and time on serum biomarkers and upper limb motor function.

RESULTS

We found significant time effects in serum IL-6 (p = 0.010), HO-1 (p = 0.002), 8-OHdG (p = 0.045), and all items/subscales of the clinical assessments (ps < 0.05), except FMA-UE-Coordination/Speed (p = 0.055). However, significant group effects existed only in items of the AROM-Elbow Extension (p = 0.007) and AROM-Forearm Pronation (p = 0.048). Moreover, significant interactions between time and group existed in item/subscales of FMA-UE-Shoulder/Elbow/Forearm (p = 0.004), FMA-UE-Total score (p = 0.008), and AROM-Shoulder Flexion (p = 0.001).

CONCLUSION

This was the first study to combine the effectiveness of immersive VRT using serum biomarkers as outcome measures. Our study demonstrated promising results that support the further application of commercial and immersive VR technologies in patients with chronic stroke.

Development and Feasibility Test of a Mouth Contactless Breathing Exercise Solution Using Virtual Reality: A Randomized Crossover Trial

PURPOSE

The purpose of this study was to develop a novel mouth contactless breathing exercise solution based on virtual reality (VR), and to test its feasibility.

METHODS

We developed the Virtual Reality-based Breathing Exercise System (VR-BRES), a self-regulating biofeedback breathing exercise with gaming characteristics and a soft stretch sensor. The feasibility and efficacy of the VR-BRES prototype were investigated through a randomized crossover trial. Fifty healthy adults participated in the trial, and their respiratory parameters and user evaluation of the VR-BRES were compared with conventional deep breathing (CDB) exercises.

RESULTS

The respiratory parameters, forced vital capacity (Z = 4.82, 4.95, p < .001), forced expiratory volume in one second (t = 6.02, 6.26, p < .001), and peak expiratory flow (t = 5.35, 5.68, p < .001) were significantly higher during breathing exercises using the VR-BRES. User evaluation was also significantly higher for the VR-BRES in terms of efficiency (Z = 3.86, p < .001), entertainingness (Z = 5.00, p < .001), and intention to use (Z = 3.22, p = .001) compared to CDB. However, there was no difference in convenience between the two methods (Z = -0.90, p = .369).

CONCLUSION

The VR-BRES has the potential to be an efficient breathing exercise solution. We recommend a clinical study that evaluates the effects of the VR-BRES for a certain period of time for people who need breathing exercises.

Effects of Virtual Reality Training on Upper Limb Function and Balance in Stroke Patients: Systematic Review and Meta-Meta-Analysis

Background

Virtual reality (VR) training is a promising intervention strategy that has been utilized in health care fields like stroke rehabilitation and psychotherapy. Current studies suggest that VR training is effective in improving the locomotor ability of stroke patients.

Objective

This is the first meta-meta-analysis of the effects of VR on motor function in stroke patients. This study aimed to systematically summarize and quantify the present meta-analyses results of VR training and produce high-quality meta-meta-analysis results to obtain a more accurate prediction.

Methods

We searched 4 online databases (Web of Science, Scopus, PubMed, and Chinese National Knowledge Infrastructure) for meta-analysis studies. After accounting for overlap, 10 studies (accounting for almost 550 stroke patients) were obtained. Based on the meta-meta-analysis of these patients, this study quantified the impact of VR training on stroke patients’ motor performance, mainly including upper limb function, balance, and walking ability. We combined the effects under the random effect model and pooled the estimates as standardized mean differences (SMD).

Results

The results of the meta-meta-analysis showed that VR training effectively improves upper limb function (SMD 4.606, 95% CI 2.733-6.479, P<.05) and balance (SMD 2.101, 95% CI 0.202-4.000, P<.05) of stroke patients. However, the results showed considerable heterogeneity and thus, may need to be treated with caution. Due to the limited research, a meta-meta-analysis of walking ability was not performed.

Conclusions

These findings represent a comprehensive body of high-quality evidence that VR training is more effective at improving upper limb function and balance of stroke patients.

Neurological complications of COVID-19: from pathophysiology to rehabilitation. An overview

OBJECTIVE

To evaluate how the SARS-COV2 is able to affect the nervous system, the main neurological manifestation, and the treatment used, including neurorehabilitation.

METHODS

Studies performed during the current year that fulfilled inclusion criteria were selected from PubMed, Scopus, Cochrane, and Web of Sciences databases. The search combined the terms "Covid 19," "rehabilitation/treatment," and "neurological complications."

RESULTS

The exact route by which SARS-CoV-2 can penetrate the CNS is still unknown, although a possible retrograde transynaptic pathway from peripheral nerve endings, and/or through the olfactory bulb, have been suggested. An early management of COVID-19 by a multiprofessional team is fundamental to avoid long term sequaele. Rehabilitation is recommended to improve respiratory and cardiac function, as well as to avoid long term neurological complications.

CONCLUSIONS

As no specific conclusions in term of prognosis and treatment could be done, research and consensus paper are needed to provide NeuroCovid patients with the best treatment options, including neurorehabilitation.

A State-of-Art Review of Digital Technologies for the Next Generation of Tinnitus Therapeutics

Background: Digital processing has enabled the development of several generations of technology for tinnitus therapy. The first digital generation was comprised of digital Hearing Aids (HAs) and personal digital music players implementing already established sound-based therapies, as well as text based information on the internet. In the second generation Smart-phone applications (apps) alone or in conjunction with HAs resulted in more therapy options for users to select from. The 3rd generation of digital tinnitus technologies began with the emergence of many novel, largely neurophysiologically-inspired, treatment theories that drove development of processing; enabled through HAs, apps, the internet and stand-alone devices. We are now of the cusp of a 4th generation that will incorporate physiological sensors, multiple transducers and AI to personalize therapies. Aim: To review technologies that will enable the next generations of digital therapies for tinnitus. Methods: A "state-of-the-art" review was undertaken to answer the question: what digital technology could be applied to tinnitus therapy in the next 10 years? Google Scholar and PubMed were searched for the 10-year period 2011-2021. The search strategy used the following key words: "tinnitus" and ["HA," "personalized therapy," "AI" (and "methods" or "applications"), "Virtual reality," "Games," "Sensors" and "Transducers"], and "Hearables." Snowballing was used to expand the search from the identified papers. The results of the review were cataloged and organized into themes. Results: This paper identified digital technologies and research on the development of smart therapies for tinnitus. AI methods that could have tinnitus applications are identified and discussed. The potential of personalized treatments and the benefits of being able to gather data in ecologically valid settings are outlined. Conclusions: There is a huge scope for the application of digital technology to tinnitus therapy, but the uncertain mechanisms underpinning tinnitus present a challenge and many posited therapeutic approaches may not be successful. Personalized AI modeling based on biometric measures obtained through various sensor types, and assessments of individual psychology and lifestyles should result in the development of smart therapy platforms for tinnitus.

Influence of Electrotherapy with Task-Oriented Training on Spasticity, Hand Function, Upper Limb Function, and Activities of Daily Living in Patients with Subacute Stroke: A Double-Blinded, Randomized, Controlled Trial

The effects of electrotherapy with task-oriented training on upper limb function in subacute stroke patients are unclear. This study investigated the influence of transcutaneous electrical nerve stimulation (TENS) with task-oriented training on spasticity, hand function, upper limb function, and activities of daily living in patients with subacute stroke. Forty-eight patients with subacute stroke were randomly assigned to either the TENS group (n = 22) or the placebo-TENS group (n = 21). High-frequency (100 Hz) TENS with below-motor threshold intensity or placebo-TENS was applied for 30 min/day, five times a week, for 4 weeks. The two groups also received task-oriented training after TENS. The Modified Ashworth Scale (MAS), Jebsen–Taylor Hand Function Test (JTHFT), Manual Function Test (MFT), and Modified Barthel Index (MBI) were used to assess spasticity, hand function, upper limb function, and activities of daily living, respectively. There was a significant time–group interaction with the MFT (p = 0.003). The TENS group showed significantly improved MAS (p = 0.003), JTHFT (p < 0.001), MFT (p < 0.001), and MBI (p < 0.001) scores after the intervention. The placebo-TENS group showed significantly improved JTHFT (p < 0.001), MFT (p = 0.001), and MBI scores (p < 0.001). There was a significant correlation between the MFT and MBI scores (p = 0.025). These results suggest that electrotherapy with task-oriented training can be used to improve upper limb function in patients with subacute stroke.

Effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke: protocol for a systematic review and meta-analysis

OBJECTIVE

To evaluate and summarize the level of evidence for the immediate, short-term, and long-term effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke.

INTRODUCTION

A game-based intervention is a valuable therapeutic tool for incorporating principles of motor learning and neuroplasticity in the rehabilitation of upper limb function post-stroke. Most of the existing reviews on game-based rehabilitation are focused on the chronic phase of stroke. However, as maximum upper limb motor recovery occurs in the first six months after stroke, further exploration of the effects of game-based rehabilitation in this phase is necessary.

INCLUSION CRITERIA

We will include randomized clinical trials assessing the immediate, short-term, and long-term effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke.

METHODS

The systematic review will follow the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist and JBI methodology for systematic reviews of effectiveness. A database-specific search strategy will be used in CINAHL, PubMed, Scopus, Web of Science, ProQuest, PEDro, OT Seeker, and Ovid MEDLINE to identify studies in the English language with no date limit. Two reviewers will independently screen, extract data from, and assess risk of bias in the eligible studies. Meta-analysis and publication bias evaluation will be done when adequate data are available. If a meta-analysis is precluded, then a narrative synthesis will be done. The Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria will be used to assess the certainty of evidence for the outcome measures of interest.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020190100.

Effectiveness of virtual reality-based rehabilitation versus conventional therapy on upper limb motor function of chronic stroke patients: a systematic review and meta-analysis of randomized controlled trials

Objective: To systematically review the available randomized controlled trials in the literature concerning the application of virtual reality (VR) rehabilitation interventions compared to conventional physical therapy, in regaining the upper limb motor function among patients with chronic stroke. Methods: A systematic electronic database search was conducted for related studies published from inauguration and until June 25, 2020 in nine databases. Another new search was done on February 1, 2021 and no new studies were identified. Results: Six studies were included in the analysis. Significant improvement was seen following the VR therapy in patients with chronic stroke, compared to their scores prior to it (SMD = 0.28; 95% CI = 0.03-0.53; p = .03). There was neither heterogeneity (I² = 0% and P = .5) nor a risk of bias (P = .8) among the included studies. VR interventions produced a comparable effectiveness to that of the conventional rehabilitation, with no statistically significant difference (SMD = 0.15; 95% CI = -0.14-0.44; P = .3). There was neither heterogeneity (I² = 40% and P = .1) nor a risk of bias (P = .5) among the included studies. Conclusions: The upper limb motor function of patients with chronic stroke who underwent VR-based rehabilitative intervention showed significant improvement as compared to the pre-treatment state. Our analysis also revealed no superiority of VR interventions over conservative therapies; however, the difference observed did not accomplish statistical significance.

Using Medical Device Standards for Design and Risk Management of Immersive Virtual Reality for At-Home Therapy and Remote Patient Monitoring

Numerous virtual reality (VR) systems have received regulatory clearance as therapeutic medical devices for in-clinic and at-home use. These systems enable remote patient monitoring of clinician-prescribed rehabilitation exercises, although most of these systems are nonimmersive. With the expanding availability of affordable and easy-to-use head-mounted display (HMD)-based VR, there is growing interest in immersive VR therapies. However, HMD-based VR presents unique risks. Following standards for medical device development, the objective of this paper is to demonstrate a risk management process for a generic immersive VR system for remote patient monitoring of at-home therapy. Regulations, standards, and guidance documents applicable to therapeutic VR design are reviewed to provide necessary background. Generic requirements for an immersive VR system for home use and remote patient monitoring are identified using predicate analysis and specified for both patients and clinicians using user stories. To analyze risk, failure modes and effects analysis, adapted for medical device risk management, is performed on the generic user stories and a set of risk control measures is proposed. Many therapeutic applications of VR would be regulated as a medical device if they were to be commercially marketed. Understanding relevant standards for design and risk management early in the development process can help expedite the availability of innovative VR therapies that are safe and effective.

Effects of Specific Virtual Reality-Based Therapy for the Rehabilitation of the Upper Limb Motor Function Post-Ictus: Randomized Controlled Trial

This research analyzed the combined effect of conventional treatment and virtual reality exposure therapy on the motor function of the upper extremities in people with stroke. We designed a randomized controlled trial set in the rehabilitation and neurology departments of a hospital (Talavera de la Reina, Spain). The subjects included 43 participants, all randomized into experimental (conventional treatment + virtual reality exposure therapy) and control group (conventional treatment).; The main measures were Fugl-Meyer Assessment for upper extremity, Modified Ashworth Scale, and Stroke Impact Scale 3.0. The results included 23 patients in the experimental (62.6 ± 13.5 years) and 20 in the control group (63.6 ± 12.2 years) who completed the study. After the intervention, muscle tone diminished in both groups, more so in the experimental group (mean baseline/post-intervention: from 1.30 to 0.60; η² = 0.237; p = 0.001). Difficulties in performing functional activities that implicate the upper limb also diminished. Regarding the global recovery from stroke, both groups improved scores, but the experimental group scored significantly higher than the controls (mean baseline/post-intervention: from 28.7 to 86.5; η² = 0.633; p = 0.000). In conclusion, conventional rehabilitation combined with specific virtual reality seems to be more efficacious than conventional physiotherapy and occupational therapy alone in improving motor function of the upper extremities and the autonomy of survivors of stroke in activities of daily living.

Virtual Reality in Neurorehabilitation: An Umbrella Review of Meta-Analyses

Neurological disorders are a leading cause of death and disability worldwide. Can virtual reality (VR) based intervention, a novel technology-driven change of paradigm in rehabilitation, reduce impairments, activity limitations, and participation restrictions? This question is directly addressed here for the first time using an umbrella review that assessed the effectiveness and quality of evidence of VR interventions in the physical and cognitive rehabilitation of patients with stroke, traumatic brain injury and cerebral palsy, identified factors that can enhance rehabilitation outcomes and addressed safety concerns. Forty-one meta-analyses were included. The data synthesis found mostly low- or very low-quality evidence that supports the effectiveness of VR interventions. Only a limited number of comparisons were rated as having moderate and high quality of evidence, but overall, results highlight potential benefits of VR for improving the ambulation function of children with cerebral palsy, mobility, balance, upper limb function, and body structure/function and activity of people with stroke, and upper limb function of people with acquired brain injury. Customization of VR systems is one important factor linked with improved outcomes. Most studies do not address safety concerns, as only nine reviews reported adverse effects. The results provide critical recommendations for the design and implementation of future VR programs, trials and systematic reviews, including the need for high quality randomized controlled trials to test principles and mechanisms, in primary studies and in meta-analyses, in order to formulate evidence-based guidelines for designing VR-based rehabilitation interventions.

Effects of Virtual Reality-Based Therapy on Quality of Life of Patients with Subacute Stroke: A Three-Month Follow-Up Randomized Controlled Trial

Objective: To evaluate the influence of conventional rehabilitation combined with virtual reality on improving quality of life related to post-stroke health. Design: Randomized controlled trial. Setting: Rehabilitation and neurology departments of a general hospital (Talavera de la Reina, Spain). Subjects: A total of 43 participants with subacute stroke. Intervention: Participants were randomized into experimental group (conventional treatment + virtual reality) and control (conventional treatment). Main measures: Health-related quality of life as measured by the EuroQoL-5 dimensions instrument (EQ-5D-5L) and EuroQoL visual analog scale (EQ-VAS). Results: A total of 23 patients in the experimental group (62.6 ± 13.5 years) and 20 in the control (63.6 ± 12.2 years) completed the study. In the experimental group, EQ-VAS score was 29.1 ± 12.8 at baseline, 86.5 ± 7.1 post-intervention, and 78.3 ± 10.3 at the three-month follow-up. The control group obtained scores of 25.5 ± 5.1, 57.0 ± 4.7, and 58.5 ± 5.9, respectively. We identified significant differences at the post-intervention and follow-up timepoints (p = 0.000) and a partial η² of 0.647. In EQ-5D-5L, the severity of issues decreased after intervention in the experimental group, while pain and anxiety dimensions increased between post-intervention and follow-up. Conclusions: The conventional rehabilitative approach combined with virtual reality appears to be more effective for improving the perceived health-related quality of life in stroke survivors.