Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults: Prevention, Plasticity, and Participation

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.

Alleviating the Effects of the COVID-19 Pandemic on the Physical, Psychological Health, and Wellbeing of Students: Coping Behavior as a Mediator

Background

Public health procedures under the COVID-19 pandemic lockdown policy negatively affect people's health. Students' physical issues have been increased due to restrictions which further impact their psychological and overall well-being.

Objective

The research looks at the influence of coping behavior in mitigating the impact of the COVID-19 epidemic on students' physical/psychological health and general well-being.

Methods

The study's participants were chosen from a pool of 2200 people using convenience sampling. Using an anonymous online poll, the main data were gathered. The collected data were analyzed by using Smart-PLS.

Results

From eight direct correlations, seven were found to be true, except the route pandemic -> overall wellbeing, which was not true. Furthermore, it was shown that the mediating effect of coping behavior was statistically significant in the routes of mediation.

Conclusion

Coping strategies have a significant role in how a person responds to trying circumstances. Our study's results suggest that coping strategies had a statistically significant mediation role in reducing the effects of the COVID-19 pandemic. It is concluded that appropriate coping strategies are an effective adaptation of a protective barrier against the damaging effects of COVID-19 on health.

Effects of virtual reality in the early-stage stroke rehabilitation: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Virtual reality (VR) is an emerging technology and has shown promising outcomes in stroke rehabilitation. VR can create an enriched environment, facilitate task-specific training, and provide multimodal sensorimotor feedback to augment functional recovery by driving the experience-dependent plasticity, which is prominent in the early-stage after stroke.

PURPOSE

This review aimed to systematically identify and examine the feasibility and effectiveness of VR intervention applied within one-month after stroke on functional outcomes of patients.

METHODS

Randomized controlled trials were searched across six databases published between 2000 and 2021. Two independent reviewers conducted study selection, data extraction, and quality assessment. Physiotherapy Evidence Database (PEDro) scale was used to evaluate the quality of included studies. Qualitative synthesis and meta-analysis were conducted to compare VR-based rehabilitation and conventional rehabilitation.

RESULTS

Seventeen randomized controlled trials were included in this review, and all of them meet the criteria for good quality. The results confirmed the feasibility of applying VR in early stroke rehabilitation. In the meta-analyses, there were no significant differences between VR and control on upper extremity function (SMD = 0.22, P = .10), Activities of Daily Living outcomes (SMD = 0.15, P = .11), balance (SMD = 0.18, P = .86), and cognition (SMD = 0.34, P = .06).

CONCLUSION

VR is a feasible approach and demonstrates comparable effectiveness in functional outcomes with conventional rehabilitation in patients with stroke at the early-stage. Further research focusing on the application of VR in acute stroke survivors with adequate sample size, additional follow-up evaluation and valid outcome measures are warranted.

Developing a serious game for gaze stability rehabilitation in children with vestibular hypofunction

BACKGROUND

Children with vestibular hypofunction (VH) may have gaze instability, balance disorders, and delayed postural-motor development. Gaze stabilization exercises (GSE) are designed to improve dynamic visual acuity (DVA). We aimed to assess the acceptability of a serious game prototype called Kid Gaze Rehab (KGR) designed to implement GSE training in children with VH, combined with traditional vestibular rehabilitation. Effects on DVA and motor performance were also analyzed.

METHODS

Twelve children (6 to 9 years old) were included. Sessions were held at the hospital twice a week, for 5 weeks. An adapted French version of The Child Simulator Sickness Questionnaire (SSQ) and the Face Scale Pain-Revised (FPS-R) were used to assess pain in the cervical region and undesirable side effects after each session. Vestibular and motor function parameters (active and passive DVA and Movement Assessment Battery for Children-Second Edition, MABC-2) were assessed before and after the training.

RESULTS

All children included completed the 10 sessions. The FPS-R visual analog scale and SSQ showed good cervical tolerance and no oculomotor or vegetative adverse effects nor spatial disorientation. After training, active DVA scores were significantly improved for the right, left, and up directions (p < 0.05). Passive DVA scores were significantly improved for the left and down directions (p < 0.01 and p < 0.05, respectively). MABC-2 scores were improved in the balance and ball skill sections (p < 0.05).

CONCLUSION

An innovative pediatric training method, the use of a dedicated serious game for gaze stabilization was well-tolerated as a complement to conventional vestibular rehabilitation in children with VH. Moreover, both DVA and motor performance were found to improve in the study sample. Although replication studies are still needed, serious game-based training in children with VH could represent a promising rehabilitation approach for years to come.

TRIAL REGISTRATION

The study was conducted in accordance with the Declaration of Helsinki and approved by an Institutional Review Board (local ethics committee, CPP Sud-Est IV, ID 2013-799). The study protocol was registered on ClinicalTrials.gov (NCT04353115).

A systematic review: Virtual-reality-based techniques for human exercises and health improvement

Virtual Reality (VR) has emerged as a new safe and efficient tool for the rehabilitation of many childhood and adulthood illnesses. VR-based therapies have the potential to improve both motor and functional skills in a wide range of age groups through cortical reorganization and the activation of various neuronal connections. Recently, the potential for using serious VR-based games that combine perceptual learning and dichoptic stimulation has been explored for the rehabilitation of ophthalmological and neurological disorders. In ophthalmology, several clinical studies have demonstrated the ability to use VR training to enhance stereopsis, contrast sensitivity, and visual acuity. The use of VR technology provides a significant advantage in training each eye individually without requiring occlusion or penalty. In neurological disorders, the majority of patients undergo recurrent episodes (relapses) of neurological impairment, however, in a few cases (60-80%), the illness progresses over time and becomes chronic, consequential in cumulated motor disability and cognitive deficits. Current research on memory restoration has been spurred by theories about brain plasticity and findings concerning the nervous system's capacity to reconstruct cellular synapses as a result of interaction with enriched environments. Therefore, the use of VR training can play an important role in the improvement of cognitive function and motor disability. Although there are several reviews in the community employing relevant Artificial Intelligence in healthcare, VR has not yet been thoroughly examined in this regard. In this systematic review, we examine the key ideas of VR-based training for prevention and control measurements in ocular diseases such as Myopia, Amblyopia, Presbyopia, and Age-related Macular Degeneration (AMD), and neurological disorders such as Alzheimer, Multiple Sclerosis (MS) Epilepsy and Autism spectrum disorder. This review highlights the fundamentals of VR technologies regarding their clinical research in healthcare. Moreover, these findings will raise community awareness of using VR training and help researchers to learn new techniques to prevent and cure different diseases. We further discuss the current challenges of using VR devices, as well as the future prospects of human training.

A Virtual Reality Exergame: Clinician-Guided Breathing and Relaxation for Children with Muscular Dystrophy

This study introduces a VR-based breathing and relaxation exergame tailored for individuals with Duchenne muscular dystrophy (DMD). DMD is a rare neuromuscular disease that leads to respiratory muscle dysfunction with anxiety being a common comorbidity. Clinical management requires frequent visits to rare disease specialists to manage symptom progression. Limited availability and/or proximity of rare disease experts present challenges to care and can lead to missed care opportunities and reduced quality of life. We propose a breathing and relaxation exergame with remote telehealth applicability that incorporates shared patient-clinician VR interaction, and physiological sensors that provide both real-time feedback to the patient and health analytics for the clinician. The game focuses on two key aspects of DMD clinical care that can be mediated through control of breathing: relaxation/mindfulness training and respiratory muscle exercise. The system was evaluated among 13 individuals, including 4 participants with DMD. Feedback surveys, interviews, and focus group discussions with participants, accompanying family members, and clinicians demonstrated the feasibility of this VR tool for telehealth or as part of a home exercise program.

Innovations in Neuropsychology: Future Applications in Neurosurgical Patient Care

Over the last century, collaboration between clinical neuropsychologists and neurosurgeons has advanced the state of the science in both disciplines. These advances have provided the field of neuropsychology with many opportunities for innovation in the care of patients prior to, during, and following neurosurgical intervention. Beyond giving a general overview of how present-day advances in technology are being applied in the practice of neuropsychology within a neurological surgery department, this article outlines new developments that are currently unfolding. Improvements in remote platform, computer interface, "real-time" analytics, mobile devices, and immersive virtual reality have the capacity to increase the customization, precision, and accessibility of neuropsychological services. In doing so, such innovations have the potential to improve outcomes and ameliorate health care disparities.

The Study of Short-Term Plastic Visual Perceptual Training Based on Virtual and Augmented Reality Technology in Amblyopia

Backgrounds. The treatment for amblyopia can have a substantial impact on quality of life. Conventional treatments for amblyopia have some limitations, then we try to explore a new and effective method to treat amblyopia. This study aimed to determine the potential effect of short-term plastic visual perceptual training based on VR and AR platforms in amblyopic patients. Methods. All observers were blinded to patient groupings. A total of 145 amblyopic children were randomly assigned into 2 groups: VR group (71 patients) and AR group (74 patients). In the VR group, each subject underwent a 20-min short-term plastic visual perceptual training based on a VR platform, and in the AR group, based on an AR platform. The best-corrected visual acuity (BCVA), fine stereopsis, and contrast sensitivity function (CSF) were measured before and after training. Results. The BCVA (P < 0.001) and fine stereopsis (P < 0.05) were improved significantly both in VR and AR group after training. Moreover, in the AR group, the CSF showed the value of all spatial frequencies had a statistically significant improvement after training (P < 0.05), while in the VR group, only the value of spatial frequency 12 improved significantly (P = 0.008). Conclusions. This study showed that the short-term plastic visual perceptual training based on VR and AR technology can improve BCVA, fine stereopsis and CSF of refractive amblyopia. It was suggested that the visual perceptual training based on the VR and AR platforms may be potentially applied in treatment for amblyopia and provided a high-immersing alternative.

ARMIA: A Sensorized Arm Wearable for Motor Rehabilitation

In this paper, we present ARMIA: a sensorized arm wearable that includes a combination of inertial and sEMG sensors to interact with serious games in telerehabilitation setups. This device reduces the cost of robotic assistance technologies to be affordable for end-users at home and at rehabilitation centers. Hardware and acquisition software specifications are described together with potential applications of ARMIA in real-life rehabilitation scenarios. A detailed comparison with similar medical technologies is provided, with a specific focus on wearable devices and virtual and augmented reality approaches. The potential advantages of the proposed device are also described showing that ARMIA could provide similar, if not better, the effectivity of physical therapy as well as giving the possibility of home-based rehabilitation.

Posterior Fossa Tumor Rehabilitation: An Up-to-Date Overview

This narrative review highlights the latest achievements in the field of post-surgical rehabilitation of posterior fossa tumors. Studies investigating the effects of cognitive rehabilitation programs have been considered, following a comprehensive literature search in the scientific electronic databases: Pubmed, Scopus, Plos One, and ScienceDirect. This review investigates the effects of cognitive remediation, with specific highlights for single cognitive domains. The results revealed that in spite of the increasing number of children who survive into adulthood, very few studies investigated the effects of rehabilitation programs in this specific population. This study details new, promising therapeutic opportunities for children after brain surgery. More research in this filed is needed to identify the most effective protocols for clinical use.

Usability evaluation of an interactive leg press training robot for children with neuromuscular impairments

BACKGROUND:

The use of robotic technology for neurorehabilitative applications has become increasingly important for adults and children with different motor impairments.

OBJECTIVE:

The aim of this study was to evaluate the technical feasibility and usability of a new interactive leg-press training robot that was developed to train leg muscle strength and control, suitable for children with neuromuscular impairments.

METHODS:

An interactive robotic training system was designed and constructed with various control strategies, actuators and force/position sensors to enable the performance of different training modes (passive, active resistance, and exergames). Five paediatric patients, aged between 7 and 16 years (one girl, age 13.0 ± 3.7 years, [mean ± SD]), with different neuromuscular impairments were recruited to participate in this study. Patients evaluated the device based on a user satisfaction questionnaire and Visual Analog Scale (VAS) scores, and therapists evaluated the device with the modified System Usability Scale (SUS).

RESULTS:

One patient could not perform the training session because of his small knee range of motion. Visual Analog Scale scores were given by the 4 patients who performed the training sessions. All the patients adjudged the training with the interactive device as satisfactory. The average SUS score given by the therapists was 61.2 ± 18.4.

CONCLUSION:

This study proposed an interactive lower limb training device for children with different neuromuscular impairments. The device is deemed feasible for paediatric rehabilitation applications, both in terms of technical feasibility and usability acceptance. Both patients and therapists provided positive feedback regarding the training with the device.

Virtual Reality Fitness (VRF) for Behavior Management During the COVID-19 Pandemic: A Mediation Analysis Approach

Background

During the COVID-19 pandemic, cellphone health apps and virtual reality fitness for treating neurological disorders such as Parkinson’s were beneficial. Virtual reality has been used to treat PTSD, depression, anxieties, dementia, ADHD, dyslexia, and pain control in various settings. Virtual reality exercise has been studied for its effects on biological, mental, rehabilitation, behavior, and attitude management.

Purpose

This research aimed to find out the role of virtual reality fitness (VRF) for behavior management during the COVID-19 pandemic concerning the demographic characteristics of the study participants and the use of fitness and health apps.

Methods

The population for the current study was Chinese residents across China who were in home isolation during the early pandemic in China. According to the study objective, a convenience sampling method was used to collect the primary data through an online survey. SPSS-25 statistical software was used to analyze the demographic information and clean and prepare the data to test all proposed hypotheses. The proposed research framework was examined using the structural equation modeling (SEM) approach through SmartPLS 3.0 software.

Results

The structural equation model analysis shows that all the proposed hypotheses (H1: β = 0.137, t = 10.454, p = <0.000; H2: β = 0.256, t = 16.824, p = <0.000; H3: β = 0.418, t = 27.827, p = <0.000; H4: β = 0.133, t = 8.913, p = <0.000; H5: β = 0.076, t = 4.717, p = <0.000; H6: β = 0.162, t = 10.532, p = <0.000; H7: β = 0.384, t = 26.645, p = <0.000) are confirmed.

Conclusion

Fitness and health apps with virtual reality fitness play a substantial role in improving the overall quality of life and positively influencing behavior and attitude.

Upper Limb Movement Measurement Systems for Cerebral Palsy: A Systematic Literature Review

Quantifying the quality of upper limb movements is fundamental to the therapeutic process of patients with cerebral palsy (CP). Several clinical methods are currently available to assess the upper limb range of motion (ROM) in children with CP. This paper focuses on identifying and describing available techniques for the quantitative assessment of the upper limb active range of motion (AROM) and kinematics in children with CP. Following the screening and exclusion of articles that did not meet the selection criteria, we analyzed 14 studies involving objective upper extremity assessments of the AROM and kinematics using optoelectronic devices, wearable sensors, and low-cost Kinect sensors in children with CP aged 4–18 years. An increase in the motor function of the upper extremity and an improvement in most of the daily tasks reviewed were reported. In the population of this study, the potential of wearable sensors and the Kinect sensor natural user interface as complementary devices for the quantitative evaluation of the upper extremity was evident. The Kinect sensor is a clinical assessment tool with a unique markerless motion capture system. Few authors had described the kinematic models and algorithms used to estimate their kinematic analysis in detail. However, the kinematic models in these studies varied from 4 to 10 segments. In addition, few authors had followed the joint assessment recommendations proposed by the International Society of Biomechanics (ISB). This review showed that three-dimensional analysis systems were used primarily for monitoring and evaluating spatiotemporal variables and kinematic parameters of upper limb movements. The results indicated that optoelectronic devices were the most commonly used systems. The joint assessment recommendations proposed by the ISB should be used because they are approved standards for human kinematic assessments. This review was registered in the PROSPERO database (CRD42021257211).

Effects of virtual reality intervention on neural plasticity in stroke rehabilitation: a systematic review

OBJECTIVE

To systematically review and examine the current literature regarding the effects of Virtual Reality (VR)-based rehabilitation on neural plasticity changes in stroke survivors.

DATA SOURCES

Six bioscience and engineering databases were searched, including Medline via Ebsco, Embase, PsycINFO, IEEE Explore, Cumulative Index of Nursing and Allied Health, and Scopus.

STUDY SELECTION

Studies reporting on the pre-post assessment of a VR intervention with neural plasticity measures published between 2000-2021 were included.

DATA EXTRACTION

Two independent reviewers conducted study selection, data extraction and quality assessment. Methodological quality of controlled trials was assessed using the Physiotherapy Evidence Database scale. Risk of bias of pre-post intervention and case studies was evaluated using the National Institutes of Health Quality Assessment Tool.

DATA SYNTHESIS

Twenty-seven studies (Total n=232) were included. Seven randomized controlled trials were rated as good quality while the two clinical controlled trials were moderate. Based on the risk of bias assessment, one pre-post study and one case study were graded as good quality, one pre-post study and one case study were poor, the other 14 studies were all at fair. After the VR intervention, main neurophysiological findings across studies include: (1) improved interhemispheric balance, (2) enhanced cortical connectivity, (3) increased cortical mapping of the affected limb muscles, (4) the improved neural plasticity measures were correlated to the enhanced behavior outcomes, (5) increased activation of regions in frontal cortex and (6) the mirror neuron system may be involved.

CONCLUSIONS

Virtual reality induced changes in neural plasticity for stroke survivors. Positive correlations between the neural plasticity changes and functional recovery elucidates the mechanisms of VR's therapeutic effects in stroke rehabilitation. This review prompts systematic understanding of the neurophysiological mechanisms of VR-based stroke rehabilitation and summarizes the emerging evidence for ongoing innovation of VR systems and application in stroke rehabilitation.

Recommendations for the Design and Implementation of Virtual Reality for Acquired Brain Injury Rehabilitation: Systematic Review

BACKGROUND

Virtual reality (VR) is increasingly being used for the assessment and treatment of impairments arising from acquired brain injuries (ABIs) due to perceived benefits over traditional methods. However, no tailored options exist for the design and implementation of VR for ABI rehabilitation and, more specifically, traumatic brain injury (TBI) rehabilitation. In addition, the evidence base lacks systematic reviews of immersive VR use for TBI rehabilitation. Recommendations for this population are important because of the many complex and diverse impairments that individuals can experience.

OBJECTIVE

This study aims to conduct a two-part systematic review to identify and synthesize existing recommendations for designing and implementing therapeutic VR for ABI rehabilitation, including TBI, and to identify current evidence for using immersive VR for TBI assessment and treatment and to map the degree to which this literature includes recommendations for VR design and implementation.

METHODS

This review was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive search of 11 databases and gray literature was conducted in August 2019 and repeated in June 2020. Studies were included if they met relevant search terms, were peer-reviewed, were written in English, and were published between 2009 and 2020. Studies were reviewed to determine the level of evidence and methodological quality. For the first part, qualitative data were synthesized and categorized via meta-synthesis. For the second part, findings were analyzed and synthesized descriptively owing to the heterogeneity of data extracted from the included studies.

RESULTS

In the first part, a total of 14 papers met the inclusion criteria. Recommendations for VR design and implementation were not specific to TBI but rather to stroke or ABI rehabilitation more broadly. The synthesis and analysis of data resulted in three key phases and nine categories of recommendations for designing and implementing VR for ABI rehabilitation. In the second part, 5 studies met the inclusion criteria. A total of 2 studies reported on VR for assessment and three for treatment. Studies were varied in terms of therapeutic targets, VR tasks, and outcome measures. VR was used to assess or treat impairments in cognition, balance, and anxiety, with positive outcomes. However, the levels of evidence, methodological quality, and inclusion of recommendations for VR design and implementation were poor.

CONCLUSIONS

There is limited research on the use of immersive VR for TBI rehabilitation. Few studies have been conducted, and there is limited inclusion of recommendations for therapeutic VR design and implementation. Future research in ABI rehabilitation should consider a stepwise approach to VR development, from early co-design studies with end users to larger controlled trials. A list of recommendations is offered to provide guidance and a more consistent model to advance clinical research in this area.

Effectiveness of Virtual Reality Interventions for Adolescent Patients in Hospital Settings: Systematic Review

Background

Given the high level of interest and increasing familiarity with virtual reality among adolescents, there is great potential to use virtual reality to address adolescents’ unique health care delivery needs while in hospital. While there have been reviews on the use of virtual reality for specific health conditions and procedures, none to date have reviewed the full scope of virtual reality hospital interventions for adolescents who are often combined with children as a homogenous group, despite the fact that adolescents experience virtual environments different from children.

Objective

The aim of this review was to systematically identify available evidence regarding the use of virtual reality interventions for adolescent patients in hospital settings to evaluate effectiveness, suitability, and safety and identify opportunities for future research.

Methods

PubMed, PsycINFO, Medline, and Scopus databases were searched using keywords and phrases. Retrieved abstracts (n=1525) were double screened, yielding 276 articles for full-text screening. Of these, 8 articles met inclusion criteria. Data were extracted to a standardized coding sheet, and a narrative synthesis was performed due to the heterogeneity of the studies.

Results

Four RCTs and 4 single-case reports were identified for inclusion, all of which aimed to reduce pain or anxiety. The scenarios targeted were burn pain, venipuncture, chemotherapy, preoperative anxiety, and palliative care. Three out of 4 RCTs found significant reductions in pain or anxiety outcomes measures when using virtual reality compared to standard care or other distraction techniques; however, only 1 study combined self-reported experiences of pain or anxiety with any physiological measures. Single-case reports relied primarily upon qualitative feedback, with patients reporting reduced pain or anxiety and a preference for virtual reality to no virtual reality.

Conclusions

Virtual reality can provide a safe and engaging way to reduce pain and anxiety in adolescents while in hospital, particularly when virtual reality software is highly immersive and specifically designed for therapeutic purposes. As VR becomes more accessible and affordable for use in hospitals, larger and more diverse studies that capitalize on adolescents’ interest in and aptitude for virtual reality, and on the full range of capabilities of this emerging technology, are needed to build on these promising results.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020198760; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020198760

The Effectiveness of Robot- vs. Virtual Reality-Based Gait Rehabilitation: A Propensity Score Matched Cohort

Robot assisted gait training (RAGT) and virtual reality plus treadmill training (VRTT) are two technologies that can support locomotion rehabilitation in children and adolescents affected by acquired brain injury (ABI). The literature provides evidence of their effectiveness in this population. However, a comparison between these methods is not available. This study aims at comparing the effectiveness of RAGT and VRTT for the gait rehabilitation of children and adolescents suffering from ABI. This is a prospective cohort study with propensity score matching. Between October 2016 and September 2018, all patients undergoing an intensive gait rehabilitation treatment based on RAGT or VRTT were prospectively observed. To minimize selection bias associated with the study design, patients who underwent RAGT or VRTT were retrospectively matched for age, gender, time elapsed from injury, level of impairment, and motor impairment using propensity score in a matching ratio of 1:1. Outcome measures were Gross Motor Function Mesure-88 (GMFM-88), six-min walking test (6MWT), Gillette Functional Assessment Questionnaire (FAQ), and three-dimensional gait analysis (GA). The FAQ and the GMFM-88 had a statistically significant increase in both groups while the 6MWT improved in the RAGT group only. GA highlighted changes at the proximal level in the RAGT group, and at the distal district in the VRTT group. Although preliminary, this work suggests that RAGT and VRTT protocols foster different motor improvements, thus recommending to couple the two therapies in the paediatric population with ABI.

A Clinical Decision-Making Framework for the Use of Video Gaming as a Therapeutic Modality

Virtual reality and video gaming offer modulation of more exercise and motor learning parameters simultaneously than other modalities; however, there is a demonstrated need for resources to facilitate their effective use clinically. This article presents a conceptual framework to guide clinical-decision making for the selection, adaptation, modulation, and progression of virtual reality or gaming when used as a therapeutic exercise modality, and two cases as exemplars. This framework was developed by adapting the steps of theory derivation, whereby concepts and parent theories are brought together to describe a new structure or phenomenon of interest. Specifically, motor learning theory, integrated motor control theory, Gentile's Taxonomy of Tasks, and therapeutic exercise principles were integrated to develop this framework. It incorporates person (body segment), environmental, and task demands; each demand is comprised of realm, category, choice, and continuum parameters as motor training considerations and alternatives for decision-making. This framework: (1) provides structure to guide clinical decisions for effective and safe use of virtual reality or gaming to meet therapeutic goals and requirements, (2) is a concise and organized method to identify, document, and track the therapeutic components of protocols and client progression over time; (3) can facilitate documentation for reimbursement and communication among clinicians; and, (4) structures student learning, and (5) informs research questions and methods.

Examining the Feasibility of Early Mobilization With Virtual Reality Gaming Using Head-Mounted Display and Adaptive Software With Adolescents in the Pediatric Intensive Care Unit: Case Report

Background

Early rehabilitative mobilization for adolescents is safe and feasible. However, there is a lack of published rehabilitation strategies and treatments that can maximize engagement and outcomes among adolescents in the pediatric intensive care unit (PICU). Virtual reality (VR) gaming using a head-mounted display (HMD) and adaptive software can allow active and nonactive gameplay at the bedside for people with limited arm mobility, making it a potentially inclusive and enjoyable treatment modality for adolescents in the PICU.

Objective

The purpose of this brief case study is to report on the preliminary feasibility of incorporating adaptive VR gaming using an HMD with 2 adolescents who received early mobility treatment within the PICU.

Methods

This study was a mini-ethnographic investigation of 2 adolescents (a 15-year-old male and a 13-year old male) in the PICU who underwent VR gaming sessions as part of their early mobilization care, using an Oculus Rift HMD and adaptive software (WalkinVR) that promoted full gameplay in bed. The Rift was plugged into a gaming laptop that was set up on a table within the patient’s room before each session. The intervention was delivered by an adapted exercise professional and supervised by a physical therapist. Patients had access to a variety of active games (eg, boxing, rhythmic movement to music, and exploratory adventure) and nonactive games (eg, racing and narrative adventure). Gaming sessions were scheduled between usual care, when tolerable and requested by the participant. The interventionist and therapists took audio-recorded and written notes after completing each gaming session. These data were analyzed and presented in a narrative format from the perspective of the research team.

Results

Case 1 participated in 4 gaming sessions, with an average of 18 minutes (SD 11) per session. Case 2 participated in 2 sessions, with an average of 35 minutes (SD 7) per session. Both cases were capable of performing active gaming at a moderate level of exercise intensity, as indicated by their heart rate. However, their health and symptoms fluctuated on a daily basis, which prompted the gameplay of adventure or nonactive games. Gameplay appeared to improve participants’ affect and alertness and motivate them to be more engaged in early mobilization therapy. Gameplay without the WalkinVR software caused several usability issues. There were no serious adverse events, but both cases experienced symptoms based on their condition.

Conclusions

The findings of this study suggest that VR gaming with HMDs and adaptive software is likely a feasible supplement to usual care for adolescents within the PICU, and these findings warrant further investigation. Recommendations for future studies aimed at incorporating VR gaming during early mobilization are presented herein.

The Virtual Challenge: Virtual Reality Tools for Intervention in Children with Developmental Coordination Disorder

This narrative review highlights the latest achievements in the field of tele-rehabilitation: Virtual Reality (VR) and Augmented Reality (AR) serious games aimed at restoring and improving cognitive functions could be effectively used in Developmental Coordination Disorder Training. Studies investigating the effects of the abovementioned tech applications on cognitive improvement have been considered, following a comprehensive literature search in the scientific electronic databases: Pubmed, Scopus, Plos One, ScienceDirect. This review investigates the effects of VR and AR in improving space/motor skills through mental images manipulation training in children with developmental coordination disorders. The results revealed that in spite of the spreading of technology, actually only four studies investigated the effects of VR/AR tools on mental images manipulation. This study highlights new, promising VR and AR based therapeutic opportunities for digital natives now available, emphasizing the advantages of using motivational reward-oriented tools, in a playful therapeutic environment. However, more research in this filed is needed to identify the most effective virtual tool set for clinical use.

Mobile-Based Health Apps to Promote Physical Activity During COVID-19 Lockdowns

Objective

Periods of lockdown due to coronavirus disease 2019 (COVID-19) have a negative effect on individuals’ physical health and quality of life, and may result in a weakened immune response, leading to enhanced risk of infection. Due to lack of access to public resources during periods of lockdown many individuals cannot perform their usual daily physical activities. The aim of this short report is to discuss the use of mobile-based health applications and virtual reality systems for promoting physical activity at home through an interactive and motivating digital environment.

Methods and results

Information on tele-health, available from the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), and data on physical activity during lockdowns were reviewed. A list of mobile-based health applications suitable for use in promoting physical activity at home was compiled.

Conclusion

This report makes recommendations for mobile-based health applications to promote physical health, which can be used at home during periods of lockdown.

Leisure-time physical activity interventions for children and adults with cerebral palsy: a scoping review

AIM

To summarize current evidence on the effects and reach of leisure-time physical activity (LTPA) interventions among children and adults with cerebral palsy (CP).

METHOD

Systematic searches were conducted in PubMed, CINAHL, and Google Scholar to identify randomized controlled trials (RCTs) of LTPA interventions in CP. Data from eligible studies were extracted for qualitative synthesis.

RESULTS

Forty-nine studies enrolled a total of 1513 participants (mean [SD] age 13y [7y], range 5-43y; 818 males, 655 females, 40 not reported) and primarily included ambulatory children. RCTs underrepresented adults and people in Gross Motor Function Classification System (GMFCS) levels IV and V. Forty-one studies reported at least one favorable benefit from LTPA. Benefits included improvements to musculoskeletal strength, cardiorespiratory fitness, quality of life, spasticity, participation, and core aspects of physical function. Regarding reach, only 34% of people that were contacted to participate enrolled within a study. A smaller percentage of participants dropped out from intervention (8%) and follow-up periods (3%).

INTERPRETATION

Study findings highlight effective interventions to improve health, fitness, and function. To enhance the reach and generalizability of LTPA trials for CP, future studies should examine how to increase study sample sizes and aim to include a better representation of adults and people in GMFCS levels IV and V.

WHAT THIS PAPER ADDS

People with cerebral palsy (CP) may experience improvements in health, fitness, and physical function from leisure-time physical activity (LTPA) interventions. Effective interventions include exercise training, active video games, recreation activities, behavioral coaching, and motor skills training. Interventions that incorporate telehealth technology, behavioral coaching, and community resources may enhance LTPA. Interventions primarily include children in Gross Motor Functional Classification System (GMFCS) levels I to III. Adults, wheelchair users, and those in GMFCS levels IV and V are underrepresented.

Active Video Games and Low-Cost Virtual Reality: An Ideal Therapeutic Modality for Children With Physical Disabilities During a Global Pandemic

Current guidelines against spread of coronavirus (COVID-19) interrupt non-essential rehabilitation services. Thus, individuals with physical disabilities such as children with cerebral palsy can no longer benefit from physical rehabilitation during this undetermined period. Using either a synchronous or asynchronous format, in collaboration with a therapist via telerehabilitation, we suggest that active video games and low-cost virtual reality are a promising delivery mode for at-home rehabilitation in the context of a global pandemic. This therapeutic modality, incorporated into an at-home individualized treatment plan, provides a means to lessen the impact of an interruption in rehabilitation services while not loosing the pre-pandemic, in-person physical activity gains. Growing evidence supports active video games and low-cost virtual reality as viable therapeutic interventions for children with physical disabilities. These technologies are especially well-accepted by pediatric populations for the ludic and motivating features that lend themselves to nearly seamless incorporation into telerehabilitation. Advantages for rehabilitation of active video games and low-cost virtual reality include a rich, challenging, multi-modal training environment in which high numbers of movement repetitions can be accomplished, and a unique opportunity to foster engaged practice actions that go beyond household activities. We offer suggestions for the clinician about how to adopt active video games and low-cost virtual reality into your practice during a global pandemic.

Telerehabilitation: Development, Application, and Need for Increased Usage in the COVID-19 Era for Patients with Spinal Pathology

The coronavirus disease 2019 (COVID-19) pandemic has triggered governments worldwide to implement severe restrictions on physical therapy protocols in order to better control the spread of the virus. One of the mechanisms of providing physical therapy patient care during this era is via telemedicine. Telerehabilitation or telerehab is a technological visual-audio system that serves patients, including those with a spine injury, ailment, or postoperatively, with neurological deficits. In this scoping review, we discuss the development of telerehab, the technological advances in the field, and the usage of telerehab specifically pertaining to spine patients, and comment on the advancement of telerehab in the time of COVID-19. There is preliminary evidence that suggests that the adoption of telerehab in lieu of face-to-face interventions is beneficial for reducing pain and improving physical function in patients afflicted with chronic nonmalignant musculoskeletal pain from low back pain, lumbar stenosis, neck pain, and osteoarthritis. Availability is important, as the necessary technology should be accessible to all participants. Safety and security should be addressed, as the passage of patient data over the Internet requires secure confidentiality. Ease-of-use is crucial to promote practicality, user-friendly operation, and adherence to therapy. The combination of evidence-based methodologies with cost-effective services will serve as a basis for the further expansion of vital telerehab services and increases reimbursement by health insurance providers.

Feasibility of a Commercially Available Virtual Reality System to Achieve Exercise Guidelines in Youth With Spina Bifida: Mixed Methods Case Study

BACKGROUND

Access to physical activity among youth with spina bifida (SB) is much lower than it is for children without disability. Enjoyable home-based exercise programs are greatly needed.

OBJECTIVE

Our objective is to examine the feasibility of a virtual reality (VR) active video gaming system (ie, bundle of consumer-available equipment) to meet US physical activity guidelines in two youth with SB.

METHODS

Two youth with SB-a 12-year-old female and a 13-year-old male; both full-time wheelchair users-participated in a brief, 4-week exercise program using a popular VR head-mounted display: Oculus Quest (Facebook Technologies). The system included a Polar H10 (Polar Canada) Bluetooth heart rate monitor, a no-cost mobile phone app (VR Health Exercise Tracker [Virtual Reality Institute of Health and Exercise]), and 13 games. The intervention protocol was conducted entirely in the homes of the participants due to the coronavirus disease 2019 (COVID-19) pandemic. The VR system was shipped to participants and they were instructed to do their best to complete 60 minutes of moderate-intensity VR exercise per day. Exercise duration, intensity, and calories expended were objectively monitored and recorded during exercise using the heart rate monitor and a mobile app. Fatigue and depression were measured via self-report questionnaires at pre- and postintervention. Participants underwent a semistructured interview with research staff at postintervention.

RESULTS

Across the intervention period, the total average minutes of all exercise performed each week for participants 1 and 2 were 281 (SD 93) and 262 (SD 55) minutes, respectively. The total average minutes of moderate-intensity exercise performed per week for participants 1 and 2 were 184 (SD 103) (184/281, 65.4%) and 215 (SD 90) (215/262, 82.1%) minutes, respectively. One participant had a reduction in their depression score, using the Quality of Life in Neurological Disorders (Neuro-QoL) test, from baseline to postintervention, but no other changes were observed for fatigue and depression scores. Participants reported that the amount of exercise they completed was far higher than what was objectively recorded, due to usability issues with the chest-worn heart rate monitor. Participants noted that they were motivated to exercise due to the enjoyment of the games and VR headset as well as support from a caregiver.

CONCLUSIONS

This study demonstrated that two youth with SB who used wheelchairs could use a VR system to independently and safely achieve exercise guidelines at home. Study findings identified a promising protocol for promoting exercise in this population and this warrants further examination in future studies with larger samples.

Virtual reality training enhances gait poststroke: a systematic review and meta-analysis

Virtual reality (VR)-based interventions are gaining widespread attention for managing neurological disorders such as stroke. A metastatistical consensus regarding the intervention is strongly warranted. In this study, we attempt to address this gap in the literature and provide the current state of evidence for the effects of VR on gait performance. We conducted both between- and within-group meta-analyses to provide a state of evidence for VR. Moreover, we conducted a search adhering to PRISMA guidelines on nine databases. Out of 1866 records, 32 studies involving a total of 809 individuals were included in this review. Considering all included studies, significant enhancements in gait parameters were observed with VR-based interventions compared with conventional therapy. A between-group meta-analysis reported beneficial significant medium effects of VR training on cadence (Hedge's g = 0.55), stride length ((STrL; Hedge's g = 0.46), and gait speed (Hedge's g = 0.30). Similarly, a within-group meta-analysis further revealed positive medium effects of VR on cadence (Hedge's g = 0.76), STrL (Hedge's g = 0.61), and gait speed (Hedge's g = 0.69). Additional subgroup analyses revealed beneficial effects of joint application of VR and robot-assisted gait training on gait speed (Hedge's g = 0.50). Collectively, findings from this review provide evidence for the effectiveness of VR-based gait training for stroke survivors.

The Potential of Virtual Reality for Inducing Neuroplasticity in Children with Amblyopia

In recent years, virtual reality (VR) has emerged as a new safe and effective tool for neurorehabilitation of different childhood and adulthood conditions. VR-based therapies can induce cortical reorganization and promote the activation of different neuronal connections over a wide range of ages, leading to contrasted improvements in motor and functional skills. The use of VR for the visual rehabilitation in amblyopia has been investigated in the last years, with the potential of using serious games combining perceptual learning and dichoptic stimulation. This combination of technologies allows the clinician to measure, treat, and control changes in interocular suppression, which is one of the factors leading to cortical alterations in amblyopia. Several clinical researches on this issue have been conducted, showing the potential of promoting visual acuity, contrast sensitivity, and stereopsis improvement. Indeed, several systems have been evaluated for amblyopia treatment including the use of different commercially available types of head mounted displays (HMDs). These HMDs are mostly well tolerated by patients during short exposures and do not cause significant long-term side effects, although their use has been occasionally associated with some visual discomfort and other complications in certain types of subjects. More studies are needed to confirm these promising therapies in controlled randomized clinical trials, with special emphasis on the definition of the most adequate planning for obtaining an effective recovery of the visual and binocular function.

What is the impact of user affect on motor learning in virtual environments after stroke? A scoping review

PURPOSE

The purported affective impact of virtual reality (VR) and active video gaming (AVG) systems is a key marketing strategy underlying their use in stroke rehabilitation, yet little is known as to how affective constructs are measured or linked to intervention outcomes. The purpose of this scoping review is to 1) explore how motivation, enjoyment, engagement, immersion and presence are measured or described in VR/AVG interventions for patients with stroke; 2) identify directional relationships between these constructs; and 3) evaluate their impact on motor learning outcomes.

METHODS

A literature search was undertaken of VR/AVG interventional studies for adults post-stroke published in Medline, PEDro and CINAHL databases between 2007 and 2017. Following screening, reviewers used an iterative charting framework to extract data about construct measurement and description. A numerical and thematic analytical approach adhered to established scoping review guidelines.

RESULTS

One hundred fifty-five studies were included in the review. Although the majority (89%; N = 138) of studies described at least one of the five constructs within their text, construct measurement took place in only 32% (N = 50) of studies. The most frequently described construct was motivation (79%, N = 123) while the most frequently measured construct was enjoyment (27%, N = 42). A summative content analysis of the 50 studies in which a construct was measured revealed that constructs were described either as a rationale for the use of VR/AVGs in rehabilitation (76%, N = 38) or as an explanation for intervention results (56%, N = 29). 38 (76%) of the studies proposed relational links between two or more constructs and/or between any construct and motor learning. No study used statistical analyses to examine these links.

CONCLUSIONS

Results indicate a clear discrepancy between the theoretical importance of affective constructs within VR/AVG interventions and actual construct measurement. Standardized terminology and outcome measures are required to better understand how enjoyment, engagement, motivation, immersion and presence contribute individually or in interaction to VR/AVG intervention effectiveness.

Feasibility of a randomised controlled trial to evaluate home-based virtual reality therapy in children with cerebral palsy

PURPOSE

Evidence is increasing for effective virtual reality therapy for motor rehabilitation for children with Cerebral Palsy. We assessed the feasibility of a virtual reality therapy mode of intervention, appropriateness of measures, and potential cost-effectiveness.

METHODS

A 12-week, 2-group, parallel-feasibility trial (ISRCT 17624388) using Nintendo Wii Fit^TM at home. Children aged 5-16, with ambulatory Cerebral Palsy, who were able to follow simple instructions were randomised to two groups; one supported by physiotherapists (individualised activity programme), the other unsupported with children having free choice (control). Children were assessed in clinic at baseline, week 6, and week 12 by blinded assessors. Feasibility of the intervention was assessed via recruitment, adherence, and usefulness of measurement tools.

RESULTS

Forty-four children were eligible (out of 48 approached): 31 consented, 30 were randomised, 21 completed the study; 10 in the supported group and 11 in the unsupported group. Nine children discontinued from tiredness, after-school activities, homework, surgery, technical difficulties or negative system feedback. The supported group completed 19 of 36 (IQR 5-35) possible sessions; the unsupported group 24 of 36 sessions (IQR 8-36). Gross Motor Function Measure scores varied by Cerebral Palsy severity after the intervention. There were no adverse events.

CONCLUSION

Virtual reality therapy offers potential as a therapeutic adjunct for children with Cerebral Palsy, warranting substantive confirmatory study. Gross Motor Function Measure, with modifications to improve sensitivity, appeared appropriate as a primary measure, with Timed up and Go test secondary. The intervention was inexpensive costing £20 per child. An explanatory trial to evaluate the clinical/cost-effectiveness of commercial system virtual reality therapy is feasible with minor methodological adaptation. Implications for rehabilitation Home-based interactive computer gaming was feasible, safe and cost effective as a therapy adjunct. Discontinue if additional pressures are present: imminent surgery, family resilience to technical difficulties, negative system feedback, after-school activities. Change in Gross Motor Function Measurement scores varied by severity of Cerebral Palsy.

Clinical Virtual Reality: Emerging Opportunities for Psychiatry

Virtual reality (VR) technology offers new opportunities for the development of innovative clinical research, assessment, and intervention tools. VR-based testing, training, teaching, and treatment approaches that would be difficult, if not impossible, to deliver with traditional methods are now being developed that take advantage of the assets that are available with VR technology. As research evidence continues to indicate clinical efficacy, VR applications are being increasingly regarded as providing innovative options for targeting the cognitive, psychological, motor, and functional impairments that result from various clinical health conditions. VR allows for the precise presentation and control of stimuli in dynamic, multisensory, 3D computer-generated simulations as well as providing advanced methods for capturing and quantifying behavioral responses. These characteristics support the rationale for the use of VR applications in clinical assessment, intervention, and training. This article begins with a brief review of the history of and rationale for the use of VR with clinical populations. It then details one use case for the clinical application of VR-the exposure-therapy treatment of anxiety disorders and posttraumatic stress disorder. Although significant work is cited in other areas of clinical VR (e.g., pain management, cognitive and physical assessment and rehabilitation, eating disorders, social skills, and clinical training), a full overview of such a broad literature is beyond the scope of this article. Thus, the authors have opted to provide more in-depth analysis of one specific clinical area that clearly illustrates how VR has been successfully applied and is supported by an encouraging and evolving scientific literature.

Does Narrative Feedback Enhance Children's Motor Learning in a Virtual Environment?

Augmented feedback has motivational and informational functions in motor learning, and is a key feature of practice in a virtual environment (VE). This study evaluated the impact of narrative (story-based) feedback as compared to standard feedback during practice of a novel task in a VE on typically developing children's motor learning, motivation and engagement. Thirty-eight children practiced navigating through a virtual path, receiving narrative or non-narrative feedback following each trial. All participants improved their performance on retention but not transfer, with no significant differences between groups. Self-reported engagement was associated with acquisition, retention and transfer for both groups. A narrative approach to feedback delivery did not offer an additive benefit; additional affective advantages of augmented feedback for motor learning in VEs should be explored.

Clinical Virtual Reality tools to advance the prevention, assessment, and treatment of PTSD

Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) military personnel has created a significant behavioural healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. The current article presents the use of Virtual Reality (VR) as a clinical tool to address the assessment, prevention, and treatment of PTSD, based on the VR projects that were evolved at the University of Southern California Institute for Creative Technologies since 2004. A brief discussion of the definition and rationale for the clinical use of VR is followed by a description of a VR application designed for the delivery of prolonged exposure (PE) for treating Service Members (SMs) and Veterans with combat- and sexual assault-related PTSD. The expansion of the virtual treatment simulations of Iraq and Afghanistan for PTSD assessment and prevention is then presented. This is followed by a forward-looking discussion that details early efforts to develop virtual human agent systems that serve the role of virtual patients for training the next generation of clinical providers, as healthcare guides that can be used to support anonymous access to trauma-relevant behavioural healthcare information, and as clinical interviewers capable of automated behaviour analysis of users to infer psychological state. The paper will conclude with a discussion of VR as a tool for breaking down barriers to care in addition to its direct application in assessment and intervention.