Virtual reality stroke rehabilitation--hype or hope?

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.

Balancing new technology: Virtual reality for balance measurement case report

RATIONALE

Falling and the inability to maintain balance are the second leading cause of unintentional injury deaths globally. There are a number of chronic and acute conditions characterized by balance difficulties, including neurological diseases, and sport injuries. Therefore, methods to monitor and quantify balance are critical for clinical decision-making regarding risk management and balance rehabilitation. New advances in virtual reality (VR) technology has identified VR as a novel therapeutic platform. VRSway is a VR application that uses sensors attached to a virtual reality headset, and handheld remote controllers for measurement and analysis of postural stability by measuring changes in spatial location relative to the center of mass and calculates various postural stability indexes. This case report evaluates balance measures in 2 healthy participants with no previous history of balance disorders using the VRSway software application and compares to output generated by the current gold standard of balance measurement, force platform technology.

CASE PRESENTATION

The primary objective of this case study was to validate the VRSway stability score for evaluation of balance. Here, we present posturography measures of the VRSway in comparison with force plate readouts in 2 healthy participants. Body Sway measurements were recorded simultaneously in both the force plate and VRSway systems. Data calculated by proprietary software is highly correlative to the data generated by force plates for each of the following measurements for participant-1 and participant-2, respectively: Sway index (r 1 = 0.985, P < .001; r 2 = 0.970, P < .001), total displacement (r 1 = 0.982, P < .001; r 2 = 0.935, P < .001), center of pressure mean velocity (r 1 = 0.982, P < .001; r 2 = 0.935, P < .001), ellipse radius 1 (r 1 = 0.979, P < .001; r 2 = 0.965, P < .001), ellipse radius 2 (r 1 = 0.982, P < .001; r 2 = 0.969, P < .001), and ellipse area (r 1 = 0.983, P < .001; r 2 = 0.969, P < .001).

CONCLUSIONS

Data from this case study suggest that VRSway measurements are highly correlated with output from force plate technology posing that VRSway is a novel approach to evaluate balance measures with VR. More research is required to understand possible uses of VR-based use for balance measurement in a larger and more diverse cohort.

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

RATIONALE

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

PATIENT CONCERNS

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

DIAGNOSIS

The patient was previously diagnosed with an ischemic stroke.

INTERVENTIONS

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

OUTCOMES

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

CONCLUSIONS

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

Recent Considerations on Gaming Console Based Training for Multiple Sclerosis Rehabilitation

Multiple Sclerosis (MS) is a well-known, chronic demyelinating disease of the Central Nervous System (CNS) and one of the most common causes of disability in young adults. In this context, one of the major challenges in patients’ rehabilitation is to maintain the gained motor abilities in terms of functional independence. This could be partially obtained by applying new emerging and cutting-edge virtual/augmented reality and serious game technologies for a playful, noninvasive treatment that was demonstrated to be quite efficient and effective in enhancing the clinical status of patients and their (re)integration into society. Recently, Cloud computing and Internet of Things (IoT) emerged as technologies that can potentially revolutionize patients’ care. To achieve such a goal, a system that on one hand gathers patients’ clinical parameters through a network of medical IoT devices equipped with sensors and that, on the other hand, sends the collected data to a hospital Cloud for processing and analytics is required. In this paper, we assess the effectiveness of a Nintendo Wii Fit^® Plus Balance Board (WFBB) used as an IoT medical device adopted in a rehabilitation training program aimed at improving the physical abilities of MS patients (pwMS). In particular, the main scientific contribution of this paper is twofold: (i) to present a preliminary new pilot study investigating whether exercises based on the Nintendo Wii Fit^® balance board included in a rehabilitation training program could improve physical abilities and Quality of Life (QoL) of patients compared to that of a conventional four-week rehabilitation training program; (ii) to discuss how such a rehabilitation training program could be adopted in the perspective of near future networks of medical IoT-based rehabilitation devices, interconnected with a hospital Cloud system for big data processing to improve patients’ therapies and support the scientific research about motor rehabilitation. Results demonstrate the advantages of our approach from both health and technological points of view.

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

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

The Use of Home-Based Nonimmersive Virtual Reality to Encourage Physical and Cognitive Exercise in People With Mild Cognitive Impairment: A Feasibility Study

Individuals with mild cognitive impairment are at risk of cognitive and physical decline. Virtual reality (VR) exercise may provide beneficial physical and cognitive exercise. The objectives of this study were to assess the feasibility and safety of home-based VR exercise and to provide pilot data for physical and cognitive efficacy. Eleven individuals with mild cognitive impairment (seven males/four females, average 78 years old, and average 3 years since diagnosis) performed a 30-min home-based VR exercise program 5 days a week for 6 weeks. The VR platform was successfully installed in participants' homes, and all participants were able to learn the VR program and progress. Participants completed 99% of the prescribed exercise. There were no major adverse events. Most participants enjoyed the VR program and reported physical benefits; fewer reported cognitive benefits. No physical or cognitive outcome measures showed change after 6 weeks. Home-based VR exercise is safe and feasible in individuals with mild cognitive impairment.

[Ethical implications in the development of functional training in mixed and augmented reality environments to treat hypertension in old age: A qualitative content analysis]

BACKGROUND

E-Health is of increasing importance in ensuring demand-oriented health care. In addition to technical feasibility, issues concerning the normative requirements for their use are growing. This paper discusses the ethical, legal and social implications of the use of mixed reality (MR) and augmented reality (AR) technologies in the therapy of elderly people with hypertension. It is based on the results of a study conducted as a part of the BMBF project BewARe.

METHODS

In the context of the above-mentioned background, an expert workshop was held with various stakeholders in an early phase of the BewARe project in accordance with the MEESTAR model, in which ethical, social and legal requirements for the development and use of AR/MR technologies were anticipated. The results of the workshop were subsequently evaluated using content analysis.

RESULTS

Content analysis identified eight main challenges for the development and use of AR/MR technologies in the therapy of elderly people with hypertension: ethical challenges for the decision-making and action capacity of older users (1), stereotyping (2), user-oriented development and implementation (3), data protection (4), support (5), health risks (6), social participation (7), and the need for an integrative approach (8).

DISCUSSION

In line with other studies, it can be shown that orientation towards medical guidelines and behavioral principles is essential to promote acceptance and adherence among end users and to minimize potential health risks. In addition, end users should be more strongly involved in the development process to overcome existing user stereotypes and establish qualification strategies for health-promoting use. Finally, legal and health economic framework conditions must be created to ensure data security and sustainable application concepts.

CONCLUSION

For a successful diffusion of AR/MR applications in health care, a holistic implementation concept is required which must involve various groups of social actors. In this context, the article discusses eight main challenges that can be understood as current challenges in this process.

Upper Limb Home-Based Robotic Rehabilitation During COVID-19 Outbreak

The coronavirus disease (COVID-19) outbreak requires rapid reshaping of rehabilitation services to include patients recovering from severe COVID-19 with post-intensive care syndromes, which results in physical deconditioning and cognitive impairments, patients with comorbid conditions, and other patients requiring physical therapy during the outbreak with no or limited access to hospital and rehabilitation centers. Considering the access barriers to quality rehabilitation settings and services imposed by social distancing and stay-at-home orders, these patients can be benefited from providing access to affordable and good quality care through home-based rehabilitation. The success of such treatment will depend highly on the intensity of the therapy and effort invested by the patient. Monitoring patients' compliance and designing a home-based rehabilitation that can mentally engage them are the critical elements in home-based therapy's success. Hence, we study the state-of-the-art telerehabilitation frameworks and robotic devices, and comment about a hybrid model that can use existing telerehabilitation framework and home-based robotic devices for treatment and simultaneously assess patient's progress remotely. Second, we comment on the patients' social support and engagement, which is critical for the success of telerehabilitation service. As the therapists are not physically present to guide the patients, we also discuss the adaptability requirement of home-based telerehabilitation. Finally, we suggest that the reformed rehabilitation services should consider both home-based solutions for enhancing the activities of daily living and an on-demand ambulatory rehabilitation unit for extensive training where we can monitor both cognitive and motor performance of the patients remotely.

A Scoping Review of Cognitive Training in Neurodegenerative Diseases via Computerized and Virtual Reality Tools: What We Know So Far

Most prevalent neurodegenerative diseases such as Alzheimer's disease, frontotemporal dementia, Parkinson's disease and multiple sclerosis are heterogeneous in their clinical profiles and underlying pathophysiology, although they typically share the presence of cognitive impairment that worsens significantly during the course of the disease. Viable pharmacological options for cognitive symptoms in these clinical conditions are currently lacking. In recent years, several studies have started to apply Computerized Cognitive Training (CCT) and Virtual Reality (VR) tools to try and contrast patients' cognitive decay over time. However, no in-depth literature review of the contribution of these promising therapeutic options across main neurodegenerative diseases has been conducted yet. The present paper reports the state-of-the-art of CCT and VR studies targeting cognitive impairment in most common neurodegenerative conditions. Our twofold aim is to point out the scientific evidence available so far and to support health professionals to consider these promising therapeutic tools when planning rehabilitative interventions, especially when the access to regular and frequent hospital consultations is not easy to be provided.

Review on motor imagery based BCI systems for upper limb post-stroke neurorehabilitation: From designing to application

Strokes are a growing cause of mortality and many stroke survivors suffer from motor impairment as well as other types of disabilities in their daily life activities. To treat these sequelae, motor imagery (MI) based brain-computer interface (BCI) systems have shown potential to serve as an effective neurorehabilitation tool for post-stroke rehabilitation therapy. In this review, different MI-BCI based strategies, including "Functional Electric Stimulation, Robotics Assistance and Hybrid Virtual Reality based Models," have been comprehensively reported for upper-limb neurorehabilitation. Each of these approaches have been presented to illustrate the in-depth advantages and challenges of the respective BCI systems. Additionally, the current state-of-the-art and main concerns regarding BCI based post-stroke neurorehabilitation devices have also been discussed. Finally, recommendations for future developments have been proposed while discussing the BCI neurorehabilitation systems.

Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review

Virtual reality and active video games (VR/AVGs) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice. However, clinical adoption remains low despite a growing evidence base and the recent development of clinically accessible and rehabilitation-specific VR/AVG systems. Given clinicians' eagerness for resources to support VR/AVG use, a critical need exists for knowledge translation (KT) interventions to facilitate VR/AVG integration into clinical practice. KT interventions have the potential to support adoption by targeting known barriers to, and facilitators of, change. This scoping review of the VR/AVG literature uses the Theoretical Domains Framework (TDF) to (1) structure an overview of known barriers and facilitators to clinical uptake of VR/AVGs for rehabilitation; (2) identify KT strategies to target these factors to facilitate adoption; and (3) report the results of these strategies. Barriers/facilitators and evaluated or proposed KT interventions spanned all but 1 and 2 TDF domains, respectively. Most frequently cited barriers/facilitators were found in the TDF domains of Knowledge, Skills, Beliefs About Capabilities, Beliefs About Consequences, Intentions, Goals, Environmental Context and Resources, and Social Influences. Few studies empirically evaluated KT interventions to support adoption; measured change in VR/AVG use did not accompany improvements in self-reported skills, attitudes, and knowledge. Recommendations to target frequently identified barriers include technology development to meet end-user needs more effectively, competency development for end-users, and facilitated VR/AVG implementation in clinical settings. Subsequent research can address knowledge gaps in both clinical and VR/AVG implementation research, including on KT intervention effectiveness and unexamined TDF domain barriers. LEVEL OF EVIDENCE: IV.

Effects of Virtual Reality Compared to Conventional Therapy on Balance Poststroke: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to systematically review the effect of virtual reality on balance as compared to conventional therapy alone poststroke.

METHODS

The databases of PubMed, Cochrane, and Ovid were searched using select keywords. The randomized controlled trials published between January 2000 and August 2017 in English language were included if they assessed the effect of virtual reality on balance ability compared to conventional therapy alone in adults' poststroke. The Physiotherapy Evidence Database scale was used to assess the methodological quality.

RESULTS

Fourteen papers were included in this review. The experimental groups largely (n = 13) used virtual reality in combination with conventional therapy. Among the high quality studies, significant between-group improvement favoring virtual reality in combination with conventional therapy was found on Berg Balance Scale (n = 7) and Timed Up and Go Scale (n = 7) when compared to conventional therapy alone. The studies were limited by low powered, small sample sizes ranging from 14 to 40, and lack of blinding, concealed allocation, and reporting of missing data. Thirteen homogenous (n = 348, I² = 37.6%, P = .083) studies were included in the meta-analysis using Berg Balance Scale. Significant improvement was observed in the experimental group compared to control group with a medium effect size of .64, confidence interval of .36-.92.

CONCLUSIONS

The findings of this review indicate that virtual reality when combined with conventional therapy is moderately more effective in improving balance than conventional therapy alone in individuals' poststroke.

Comparing classification techniques for identification of grasped objects

BACKGROUND

This work presents a comparison and selection of different machine learning classification techniques applied in the identification of objects using data collected by an instrumented glove during a grasp process. The selected classifiers techniques can be applied to e-rehabilitation and e-training exercises for different pathologies, as in aphasic patients.

METHODS

The adopted method uses the data from a commercial instrumented glove. An experiment was carried out, where three subjects using an instrumented glove had to grasp eight objects of common use. The collected data were submitted to nineteen different classification techniques (available on the scikit-learn library of Python) used in two classifier structures, with the objective of identifying the grasped object. The data were organized into two dataset scenarios: one with data from the three users and another with individual data.

RESULTS

As a result of this work, three classification techniques presented similar accuracies for the classification of objects. Also, it was identified that when training the models with individual dataset the accuracy improves from 96 to 99%.

CONCLUSIONS

Classification techniques were used in two classifier structures, one based on a single model and the other on a cascade model. For both classifier structure and scenarios, three of the classification techniques were selected due to the high reached accuracies. The highest results were obtained using the classifier structure that employed the cascade models and the scenario of individual dataset.

A Game Changer: 'The Use of Digital Technologies in the Management of Upper Limb Rehabilitation'

Hemiparesis is a symptom of residual weakness in half of the body, including the upper extremity, which affects the majority of post stroke survivors. Upper limb function is essential for daily life and reduction in movements can lead to tremendous decline in quality of life and independence. Current treatments, such as physiotherapy, aim to improve motor functions, however due to increasing NHS pressure, growing recognition on mental health, and close scrutiny on disease spending there is an urgent need for new approaches to be developed rapidly and sufficient resources devoted to stroke disease. Fortunately, a range of digital technologies has led to revived rehabilitation techniques in captivating and stimulating environments. To gain further insight, a meta-analysis literature search was carried out using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) method. Articles were categorized and pooled into the following groups; pro/anti/neutral for the use of digital technology. Additionally, most literature is rationalised by quantitative and qualitative findings. Findings displayed, the majority of the inclusive literature is supportive of the use of digital technologies in the rehabilitation of upper extremity following stroke. Overall, the review highlights a wide understanding and promise directed into introducing devices into a clinical setting. Analysis of all four categories; (1) Digital Technology, (2) Virtual Reality, (3) Robotics and (4) Leap Motion displayed varying qualities both-pro and negative across each device. Prevailing developments on use of these technologies highlights an evolutionary and revolutionary step into utilizing digital technologies for rehabilitation purposes due to the vast functional gains and engagement levels experienced by patients. The influx of more commercialised and accessible devices could alter stroke recovery further with initial recommendations for combination therapy utilizing conventional and digital resources.

A video-game group intervention: Experiences and perceptions of adults with chronic stroke and their therapists: Intervention de groupe à l'aide de jeux vidéo : Expériences et perceptions d'adultes en phase chronique d'un accident vasculaire cérébral et de leurs ergothérapeutes

BACKGROUND

Ongoing physical activity is important for maintaining the functional level of individuals with chronic stroke. Video games in a group setting might be a cost-effective way for providing mobility and preventing physical inactivity.

PURPOSE

This study explores the experiences and perceptions of individuals with chronic stroke who participated in a novel community-based video-game group intervention and their therapists.

METHOD

A qualitative study, nested in a randomized controlled trial, was conducted using semistructured interviews with eight individuals with chronic stroke (four men and four women) ages 29 to 69 and a focus group of their three occupational therapists, following a video-game intervention. Data were analyzed using content analysis.

FINDINGS

Three main categories were identified by the study participants: (a) using video games, (b) the group/team experience, and (c) intervention outcomes/evolving understandings following the intervention.

IMPLICATIONS

Playing video games was perceived not as treatment but as a motivating tool to facilitate whole-body movement. Therefore, this intervention might be suitable to be used in the community for ongoing intervention.

The effects of semi-immersive virtual reality therapy on standing balance and upright mobility function in individuals with chronic incomplete spinal cord injury: A preliminary study

BACKGROUND

Individuals with chronic incomplete spinal cord injury (iSCI) commonly face persistent balance or mobility impairments. Virtual reality (VR) therapy is a useful rehabilitation approach; however, little is known about its effects in individuals with chronic iSCI.

OBJECTIVE

To investigate the effects of semi-immersive VR therapy on standing balance and upright mobility function in individuals with chronic iSCI.

METHODS

Ten subjects with chronic iSCI underwent VR therapy 30 minutes a day, 3 days a week, for 6 weeks. Limit of stability (LOS) and the Berg Balance Scale (BBS) were used to evaluate standing balance function. The Timed Up & Go (TUG) test, Activities-specific Balance Confidence (ABS) Scale, and Walking Index for Spinal Cord Injury-II (WISCI-II) were used to measure the subject's upright mobility function. Outcomes were assessed and recorded pre- and post-intervention.

RESULTS

After semi-immersive VR therapy, LOS and BBS scores were significantly increased. In addition, the TUG test results increased significantly over time, while ABC scale scores and WSCI-II levels improved significantly.

CONCLUSION

This study is the first to assess the effects of semi-immersive VR therapy for patients with chronic iSCI and limited functional abilities. These results indicated that semi-immersive VR therapy has a positive effect and is a useful intervention for standing balance and upright mobility function in patients with chronic iSCI.

The Effect of a Virtual Reality Game Intervention on Balance for Patients with Stroke: A Randomized Controlled Trial

OBJECTIVE

The aim of this study was to investigate the effects of virtual reality (VR) balance training conducted using Kinect for Xbox® games on patients with chronic stroke.

MATERIALS AND METHODS

Fifty patients with mild to moderate motor deficits were recruited and randomly assigned to two groups: VR plus standard treatment group and standard treatment (ST) group. In total, 12 training sessions (90 minutes a session, twice a week) were conducted in both groups, and performance was assessed at three time points (pretest, post-test, and follow-up) by a blinded assessor. The outcome measures were the Berg Balance Scale (BBS), Functional Reach Test, and Timed Up and Go Test (cognitive; TUG-cog) for balance evaluations; Modified Barthel Index for activities of daily living ability; Activities-specific Balance Confidence Scale for balance confidence; and Stroke Impact Scale for quality of life. The pleasure scale and adverse events were also recorded after each training session.

RESULTS

Both groups exhibited significant improvement over time in the BBS (P = 0.000) and TUG-cog test (P = 0.005). The VR group rated the experience as more pleasurable than the ST group during the intervention (P = 0.027). However, no significant difference was observed in other outcome measures within or between the groups. No serious adverse events were observed during the treatment in either group.

CONCLUSIONS

VR balance training by using Kinect for Xbox games plus the traditional method had positive effects on the balance ability of patients with chronic stroke. The VR group experienced higher pleasure than the ST group during the intervention.

Gamification in Physical Therapy: More Than Using Games

The implementation of computer games in physical therapy is motivated by characteristics such as attractiveness, motivation, and engagement, but these do not guarantee the intended therapeutic effect of the interventions. Yet, these characteristics are important variables in physical therapy interventions because they involve reward-related dopaminergic systems in the brain that are known to facilitate learning through long-term potentiation of neural connections. In this perspective we propose a way to apply game design approaches to therapy development by "designing" therapy sessions in such a way as to trigger physical and cognitive behavioral patterns required for treatment and neurological recovery. We also advocate that improving game knowledge among therapists and improving communication between therapists and game designers may lead to a novel avenue in designing applied games with specific therapeutic input, thereby making gamification in therapy a realistic and promising future that may optimize clinical practice.

Elderly people's perceptions of using Wii sports bowling - A qualitative study

The Nintendo Wii is a gaming console with motion-sensitive controls that is making inroads into health care and rehabilitation. However, there is still limited knowledge on how elderly people perceive the use of such a product. The aim of this study was to examine how the use of the Wii Sports Bowling in an activity group was perceived by elderly people. The data consisted of observations and interviews with participants who used Wii Sports Bowling and was analysed with content analysis. The findings are described in three themes; 'The use of the Wii Sports game', 'Engagement in the game' and 'Social interaction around the activity'. Wii Sports Bowling was described as easier to play compared to real-life bowling and was enjoyable and a social activity. The opportunity to meet the group each week was important for the participants. Playing the game resulted in signs of immersion and a flow-like state. The Wii was perceived to be easy to use, to provide a way to socialize with peers and to give opportunities to participate in activities in a new way. More studies regarding elderly people's experiences and apprehensions regarding new technology such as gaming consoles and virtual reality are needed.

Using health games for rehabilitation of patients with infantile cerebral palsy

[Purpose] The purposes of this study were to evaluate whether the therapeutic games developed by the study team are significantly effective for upper limb rehabilitation of patients with cerebral palsy and to assess the development of the games and the evolution of patients throughout the therapy sessions. [Subjects and Methods] This study demonstrates the results of using therapeutic games in patients with infantile cerebral palsy. The therapies were performed in 30-minute sessions for about 1 to 4 months. This study shows the progress of five children with cerebral palsy during the sessions. The time it took the children on each road and the times required to complete a task were measured. In addition, the level of difficulty of the games was gradually increased at each session. [Results] Results have shown good progress on the accuracy of the movements and an increase in concentration level during the execution of the games, showing an improvement in the patients' performance by 40-55% faster. [Conclusions] Health games encourage children to comply with therapy. The advantage of the game is that the patient can perform the therapy at home, which could help achieve further progress in patients.

Virtual reality in multiple sclerosis - A systematic review

INTRODUCTION

Multiple sclerosis (MS) is an inflammatory disease in which the insulating cover of nerve cells in the brain and spinal cord are damaged. The methods used for motor rehabilitation of patients with neurological problems require the performance of several rehabilitation exercises. Recently, studies related to the use of video game consoles have proliferated in the field of motor rehabilitation. Virtual reality (VR) has been proposed as a potentially useful tool for motoring assessment and rehabilitation.

OBJECTIVE

The purpose of this study was to investigate the results shown in previous studies on "Multiple Sclerosis" and "Virtual Reality".

METHOD

A bibliographic review was performed without time limitations. The research was carried out using PubMed and BVS databases. Considering keywords, we included articles that showed the terms "Multiple Sclerosis" and "Virtual Reality". The review was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines

RESULTS

The initial search yielded 41 articles. After the duplicates were removed, two authors independently evaluated the title and abstract of each of the articles with the study inclusion criteria. From these, 31 articles were excluded based on the title and abstract. Finally, 10 articles were isolated that met the inclusion criteria.

CONCLUSION

VR represents a motivational and effective alternative to traditional motor rehabilitation for MS patients. The results showed that VR programs could be an effective method of patients with MS rehabilitation in multiple cognitive and / or motor deficits. Additional research is needed to support the rehabilitation protocols with VR and increase the effects of treatment.

Virtual rehabilitation: What are the practical barriers for home-based research?

Virtual reality technologies are becoming increasingly accessible and affordable to deliver, and consequently the interest in applying virtual reality within rehabilitation is growing. This has resulted in the emergence of research exploring the utility of virtual reality and interactive video gaming interventions for home use by patients. The aim of this paper is to highlight the practical factors and difficulties that may be encountered in research in this area, and to make recommendations for addressing these. Whilst this paper focuses on examples drawn mainly from stroke rehabilitation research, many of the issues raised are relevant to other conditions where virtual reality approaches have the potential to be applied to home-based rehabilitation.

"Kinect-ing" with clinicians: a knowledge translation resource to support decision making about video game use in rehabilitation

Microsoft's Kinect for Xbox 360 virtual reality (VR) video games are promising rehabilitation options because they involve motivating, full-body movement practice. However, these games were designed for recreational use, which creates challenges for clinical implementation. Busy clinicians require decision-making support to inform game selection and implementation that address individual therapeutic goals. This article describes the development and preliminary evaluation of a knowledge translation (KT) resource to support clinical decision making about selection and use of Kinect games in physical therapy. The knowledge-to-action framework guided the development of the Kinecting With Clinicians (KWiC) resource. Five physical therapists with VR and video game expertise analyzed the Kinect Adventure games. A consensus-building method was used to arrive at categories to organize clinically relevant attributes guiding game selection and game play. The process and results of an exploratory usability evaluation of the KWiC resource by clinicians through interviews and focus groups at 4 clinical sites is described. Subsequent steps in the evaluation and KT process are proposed, including making the KWiC resource Web-based and evaluating the utility of the online resource in clinical practice.

Is it possible to use highly realistic virtual reality in the elderly? A feasibility study with image-based rendering

BACKGROUND

Virtual reality (VR) opens up a vast number of possibilities in many domains of therapy. The primary objective of the present study was to evaluate the acceptability for elderly subjects of a VR experience using the image-based rendering virtual environment (IBVE) approach and secondly to test the hypothesis that visual cues using VR may enhance the generation of autobiographical memories.

METHODS

Eighteen healthy volunteers (mean age 68.2 years) presenting memory complaints with a Mini-Mental State Examination score higher than 27 and no history of neuropsychiatric disease were included. Participants were asked to perform an autobiographical fluency task in four conditions. The first condition was a baseline grey screen, the second was a photograph of a well-known location in the participant's home city (FamPhoto), and the last two conditions displayed VR, ie, a familiar image-based virtual environment (FamIBVE) consisting of an image-based representation of a known landmark square in the center of the city of experimentation (Nice) and an unknown image-based virtual environment (UnknoIBVE), which was captured in a public housing neighborhood containing unrecognizable building fronts. After each of the four experimental conditions, participants filled in self-report questionnaires to assess the task acceptability (levels of emotion, motivation, security, fatigue, and familiarity). CyberSickness and Presence questionnaires were also assessed after the two VR conditions. Autobiographical memory was assessed using a verbal fluency task and quality of the recollection was assessed using the "remember/know" procedure.

RESULTS

All subjects completed the experiment. Sense of security and fatigue were not significantly different between the conditions with and without VR. The FamPhoto condition yielded a higher emotion score than the other conditions (P<0.05). The CyberSickness questionnaire showed that participants did not experience sickness during the experiment across the VR conditions. VR stimulates autobiographical memory, as demonstrated by the increased total number of responses on the autobiographical fluency task and the increased number of conscious recollections of memories for familiar versus unknown scenes (P<0.01).

CONCLUSION

The study indicates that VR using the FamIBVE system is well tolerated by the elderly. VR can also stimulate recollections of autobiographical memory and convey familiarity of a given scene, which is an essential requirement for use of VR during reminiscence therapy.

Occupational therapists' views on using a virtual reality interior design application within the pre-discharge home visit process

BACKGROUND

A key role of Occupational Therapists (OTs) is to carry out pre-discharge home visits (PHV) and propose appropriate adaptations to the home environment in order to enable patients to function independently after hospital discharge. However, research shows that more than 50% of specialist equipment installed as part of home adaptations is not used by patients. A key reason for this is that decisions about home adaptations are often made without adequate collaboration and consultation with the patient. Consequently, there is an urgent need to seek out new and innovative uses of technology to facilitate patient/practitioner collaboration, engagement, and shared decision making in the PHV process. Virtual reality interior design applications (VRIDAs) primarily allow users to simulate the home environment and visualize changes prior to implementing them. Customized VRIDAs, which also model specialist occupational therapy equipment, could become a valuable tool to facilitate improved patient/practitioner collaboration, if developed effectively and integrated into the PHV process.

OBJECTIVE

The intent of the study was to explore the perceptions of OTs with regard to using VRIDAs as an assistive tool within the PHV process.

METHODS

Task-oriented interactive usability sessions, utilizing the think-aloud protocol and subsequent semi-structured interviews were carried out with seven OTs who possessed significant experience across a range of clinical settings. Template analysis was carried out on the think-aloud and interview data. Analysis was both inductive and driven by theory, centering around the parameters that impact upon the acceptance, adoption, and use of this technology in practice as indicated by the Technology Acceptance Model (TAM).

RESULTS

OTs' perceptions were identified relating to three core themes: (1) perceived usefulness (PU), (2) perceived ease of use (PEoU), and (3) actual use (AU). Regarding PU, OTs believed VRIDAs had promising potential to increase understanding, enrich communication and patient involvement, and improve patient/practitioner shared understanding. However, it was unlikely that VRIDAs would be suitable for use with cognitively impaired patients. For PEoU, all OTs were able to use the software and complete the tasks successfully; however, participants noted numerous specialist equipment items that could be added to the furniture library. AU perceptions were positive regarding use of the application across a range of clinical settings including children/young adults, long-term conditions, neurology, older adults, and social services. However, some "fine tuning" may be necessary if the application is to be optimally used in practice.

CONCLUSIONS

Participants perceived the use of VRIDAs in practice would enhance levels of patient/practitioner collaboration and provide a much needed mechanism via which patients are empowered to become more equal partners in decisions made about their care. Further research is needed to explore patient perceptions of VRIDAs, to make necessary customizations accordingly, and to explore deployment of the application in a collaborative patient/practitioner-based context.

Influence of altered visual feedback on neck movement for a virtual reality rehabilitative system

This paper investigates altering visual feedback during neck movement through control-display (C-D) gain for a head-mounted display, for the purpose of determining the just noticeable difference (JND) for encouraging individuals with kinesiophobia (i.e. fear avoidance of movement due to chronic pain) to effectively perform therapeutic neck exercises. The JND was defined as .25 probability of detecting a difference from unity C-D gain (gain=1). A target-aiming task with two consecutive neck moves per trial was presented; one neck move had varying C-D gain and the other had unity gain. The VR system was able to influence neck moves without changing locations of the target. Participants indicated whether the two neck movements were the same or different. Logistic regression revealed that the JND gains were 0.903 (lower bound) and 1.159 (upper bound) as the participants could not discriminate a 55° turn, ranging from 49.7° to 63.7°. This preliminary study shows that immersive VR with altered visual feedback influenced movement. The feasibility for rehabilitation of individuals with kinesiophobia will next be assessed.

Clinical usefulness of the virtual reality-based postural control training on the gait ability in patients with stroke

This study is a single blind randomized controlled trial to determine the effect of virtual reality-based postural control training on the gait ability in patients with chronic stroke. Sixteen subjects were randomly assigned to either experimental group (VR, n= 8) or control group (CPT, n= 8). Subjects in both groups received conventional physical therapy for 60 min per day, five days per week during a period of four weeks. Subjects in the VR group received additional augmented reality-based training for 30 min per day, three days per week during a period of four weeks. The subjects were evaluated one week before and after participating in a four week training and follow-up at one month post-training. Data derived from the gait analyses included spatiotemporal gait parameters, 10 meters walking test (10 mWT). In the gait parameters, subjects in the VR group showed significant improvement, except for cadence at post-training and follow-up within the experimental group. However, no obvious significant improvement was observed within the control group. In between group comparisons, the experimental group (VR group) showed significantly greater improvement only in stride length compared with the control group (P< 0.05), however, no significant difference was observed in other gait parameters. In conclusion, we demonstrate significant improvement in gait ability in chronic stroke patients who received virtual reality based postural control training. These findings suggest that virtual reality (VR) postural control training using real-time information may be a useful approach for enhancement of gait ability in patients with chronic stroke.

Active video-gaming effects on balance and mobility in individuals with chronic stroke: a randomized controlled trial

BACKGROUND

Treatments that provide feedback, increase practice with multiple repetitions, and motivate patients are essential to rehabilitation post stroke.

OBJECTIVE

To determine whether playing active video games results in improved balance and mobility post stroke.

METHODS

Thirty participants with chronic (time since stroke = 3.0 [2.9] years) hemiparesis post stroke were randomly assigned to a gaming group or normal activity control group. Gaming systems provided participants with an interactive interface of real-time movement of either themselves or an avatar on the screen. Participants played games 50-60 minutes/day, 4 days/week, for 5 weeks. The intervention was strictly game-play, in standing position, without physical therapy. The control group received no special intervention and continued with normal activity. Both groups were tested prior to, following the 5 weeks (post test), and 3 months following the completion of the study. Outcome measures included the Fugl-Meyer Assessment, Berg Balance Scale, Dynamic Gait Index, Timed Up & Go, 6-minute walk test, 3-meter walk (self-selected and fast), and perception of recovery.

RESULTS

No statistically significant differences between or within groups were found through analysis of covariance (covaried for side of hemiparesis) at post test or follow-up. Although the within-group effect sizes were primarily indexed as "small" (< .36), the gaming group exhibited higher within-group effect sizes before and after testing than did the control group on all 7 dependent variables analyzed.

CONCLUSIONS

Even though the only intervention was game-play, there were small positive effects. Therapist assistance in making more optimum movement choices may be needed before significant improvements are seen with commercially available, general purpose games.

Computer Games as Therapy for Persons with Stroke

BACKGROUND

Stroke affects approximately 800,000 individuals each year, with 65% having residual impairments. Studies have demonstrated that mass practice leads to regaining motor function in affected extremities; however, traditional therapy does not include the repetitions needed for this recovery. Videogames have been shown to be good motivators to complete repetitions. Advances in technology and low-cost hardware bring new opportunities to use computer games during stroke therapy. This study examined the use of the Microsoft (Redmond, WA) Kinect™ and Flexible Action and Articulated Skeleton Toolkit (FAAST) software as a therapy tool to play existing free computer games on the Internet.

SUBJECTS AND METHODS

Three participants attended a 1-hour session where they played two games with upper extremity movements as game controls. Video was taken for analysis of movement repetitions, and questions were answered about participant history and their perceptions of the games.

RESULTS

Participants remained engaged through both games; regardless of previous computer use all participants successfully played two games. Five minutes of game play averaged 34 repetitions of the affected extremity. The Intrinsic Motivation Inventory showed a high level of satisfaction in two of the three participants.

CONCLUSIONS

The Kinect Sensor with the FAAST software has the potential to be an economical tool to be used alongside traditional therapy to increase the number of repetitions completed in a motivating and engaging way for clients.

A Scoping Review of Health Game Research: Past, Present, and Future

Health game research has flourished over the last decade. The number of peer-reviewed scientific publications has surged as the clinical application of health games has diversified. In response to this growth, several past literature reviews have assessed the effectiveness of health games in specific clinical subdomains. The past literature reviews, however, have not provided a general scope of health games independent of clinical context. The present systematic review identified 149 publications. All sources were published before 2011 in a peer-reviewed venue. To be included in this review, publications were required (1) to be an original research, (2) to focus on health, (3) to utilize a sound research design, (4) to report quantitative health outcomes, and (5) to target healthcare receivers. Initial findings showed certain trends in health game publications: Focus on younger male demographics, relatively low number of study participants, increased number of controlled trials, short duration of intervention periods, short duration and frequency of user-game interaction, dominance of exercise and rehab games, lack of underlying theoretical frameworks, and concentration on clinical contexts such as physical activity and nutrition. The review concludes that future research should (1) widen the demographics to include females and elderly, (2) increase the number of participants in controlled trials, (3) lengthen both the intervention period and user-game interaction duration, and (4) expand the application of health games in new clinical contexts.

Stroke patients' experiences with Wii Sports® during inpatient rehabilitation

INTRODUCTION

Commercial virtual reality games have been used as adjunct therapy for stroke rehabilitation, mainly after patients have been discharged. The aim of this study was to explore stroke patients' experiences with Wii Sports® as a supplement to conventional occupational therapy in a controlled hospital setting.

MATERIALS AND METHODS

The study had a qualitative triangulation design that included semi-structured interviews and field notes. Nine Danish stroke patients participated, receiving between one and nine interventions with Wii Sports® during a three-week period. Responses were coded by qualitative content analysis.

RESULTS

Analysis revealed one overarching category, "Connecting to past, present, and future occupations", and three categories that encompassed patients' experiences with Wii: (i) variety, (ii) engagement, and (iii) obstacles and challenges. Interview findings were confirmed by field notes that included observations of engagement and challenges.

DISCUSSION

Stroke patients in hospital settings may experience Wii Sports® as a beneficial and challenging occupation for both rehabilitation and leisure. Incorporation of Wii Sports® into conventional occupational therapy services may benefit patient rehabilitation directly or provide motivation for alternative leisure activities.