A novel fully immersive virtual reality environment for upper extremity rehabilitation in patients with stroke

How does combining physical therapy with transcranial direct stimulation improve upper-limb motor functions in patients with stroke? A theory perspective

More than half of stroke survivors suffer from upper-limb dysfunction that persists years after stroke, negatively impacting patients' independence and, therefore, affecting their quality of life. Intense motor rehabilitation is required after a stroke to facilitate motor recovery. More importantly, finding new ways to maximize patients' motor recovery is a core goal of stroke rehabilitation. Thus, researchers have explored the potential benefits of combining the effects of non-invasive brain stimulation with physical therapy rehabilitation. Specifically, combining transcranial direct stimulation (tDCS) with neurorehabilitation interventions can boost the brain's responses to interventions and maximize the effects of rehabilitation to improve upper-limb recovery post-stroke. However, it is still unclear which modes of tDCS are optimal for upper-limb motor recovery in patients with stroke when combined with physical therapy interventions. Here, the authors review the existing literature suggesting combining physical therapy rehabilitation with tDCS can maximize patients' motor recovery using the Interhemispheric Competition Model in Stroke. The authors focus on two main rehabilitation paradigms, which are constraint-induced movement therapy (CIMT) and Mirror therapy with and without tDCS. The authors also discuss potential studies to elucidate further the benefit of using tDCS adjunct with these upper-limb rehabilitation paradigms and its effectiveness in patients with stroke, with the ultimate goal of maximizing patients' motor recovery.

The Technology to Enhance Patient Motivation in Virtual Reality Rehabilitation: A Review

Virtual reality (VR) technology has experienced a steady rise and has been widely applied in the field of rehabilitation. The integration of VR technology in rehabilitation has shown promising results in enhancing their motivation for treatment, thereby enabling patients to actively engage in rehab training. Despite the advancement, there is a dearth of comprehensive summary and analysis on the use of VR technology to enhance patient motivation in rehabilitation. Thus, this narrative review aims to evaluate the potential of VR technology in enhancing patient motivation during motor rehabilitation training. This review commences with an explanation of how enhancing motivation through the VR rehabilitation system could improve the efficiency and effectiveness of rehabilitation training. Then, the technology was analyzed to improve patient motivation in the present VR rehabilitation system in detail. Furthermore, these technologies are classified and summarized to provide a comprehensive overview of the state-of-the-art approaches for enhancing patient motivation in VR rehabilitation. Findings showed VR rehabilitation training utilizes game-like exercises to enhance the engagement and enjoyment of rehabilitation training. By immersing patients in a simulated environment with multisensory feedback, VR systems offer a unique approach to rehabilitation that can lead to improved patient motivation. Both ultimately lead to improved patient outcomes, which is not typically achievable with traditional rehabilitation methods. The review concludes that VR rehabilitation presents an opportunity to improve patient motivation and adherence to long-term rehabilitation training. However, to further enhance patient self-efficacy, VR rehabilitation should integrate psychology and incorporate methods. Moreover, it is necessary to build a game design theory for rehabilitation games, and the latest VR feedback technology should also be introduced.

Technological Features of Immersive Virtual Reality Systems for Upper Limb Stroke Rehabilitation: A Systematic Review

Stroke is the second most common cause of death worldwide, and it greatly impacts the quality of life for survivors by causing impairments in their upper limbs. Due to the difficulties in accessing rehabilitation services, immersive virtual reality (IVR) is an interesting approach to improve the availability of rehabilitation services. This systematic review evaluates the technological characteristics of IVR systems used in the rehabilitation of upper limb stroke patients. Twenty-five publications were included. Various technical aspects such as game engines, programming languages, headsets, platforms, game genres, and technical evaluation were extracted from these papers. Unity 3D and C# are the primary tools for creating IVR apps, while the Oculus Quest (Meta Platforms Technologies, Menlo Park, CA, USA) is the most often used headset. The majority of systems are created specifically for rehabilitation purposes rather than being readily available for purchase (i.e., commercial games). The analysis also highlights key areas for future research, such as game assessment, the combination of hardware and software, and the potential integration incorporation of biofeedback sensors. The study highlights the significance of technological progress in improving the effectiveness and user-friendliness of IVR. It calls for additional research to fully exploit IVR's potential in enhancing stroke rehabilitation results.

Study of the Possibility of Using Virtual Reality Application in Rehabilitation among Elderly Post-Stroke Patients

Thanks to medical advances, life expectancy is increasing. With it comes an increased incidence of diseases, of which age is a risk factor. Stroke is among these diseases, and is one of the causes of long-term disability. The opportunity to treat these patients is via rehabilitation. A promising new technology that can enhance rehabilitation is virtual reality (VR). However, this technology is not widely used by elderly patients, and, moreover, the elderly often do not use modern technology at all. It therefore becomes a legitimate question whether elderly people will be able to use virtual reality in rehabilitation. This article presents a rehabilitation application dedicated to patients with upper limb paresis and unilateral spatial neglect (USN). The application was tested on a group of 60 individuals including 30 post-stroke patients with an average age of 72.83 years. The results of the conducted study include a self-assessment by the patients, the physiotherapist's evaluation, as well as the patients' performance of the exercise in VR. The study showed that elderly post-stroke patients are able to use virtual reality applications, but the ability to correctly and fully perform an exercise in VR depends on several factors. One of them is the ability to make logical contact (p = 0.0001 < 0.05). However, the study presented here shows that the ability to use VR applications does not depend on age but on mental and physical condition, which gives hope that virtual reality applications can be used in post-stroke rehabilitation among patients of all ages.

Evidence of mirror therapy for recruitment of ipsilateral motor pathways in stroke recovery: A resting fMRI study

Mirror therapy (MT) has been proposed to promote motor recovery post-stroke through activation of mirror neuron system, recruitment of ipsilateral motor pathways, or/and increasing attention toward the affected limb. However, neuroimaging evidence for these mechanisms is still lacking. To uncover the underlying mechanisms, we designed a randomized controlled study and used a voxel-based whole-brain analysis of resting-state fMRI to explore the brain reorganizations induced by MT. Thirty-five stroke patients were randomized to an MT group (n ​= ​16) and a conventional therapy (CT) group (n ​= ​19) for a 4-week intervention. Before and after the intervention, the Fugl-Meyer Assessment Upper Limb subscale (FMA-UL) and resting-state fMRI were collected. A healthy cohort (n ​= ​16) was established for fMRI comparison. The changes in fractional amplitude of low-frequency fluctuation (fALFF) and seed-based functional connectivity were analyzed to investigate the impact of intervention. Results showed that greater FMA-UL improvement in the MT group was associated with the compensatory increase of fALFF in the contralesional precentral gyrus (M1) region and the re-establishment of functional connectivity between the bilateral M1 regions, which facilitate motor signals transmission via the ipsilateral motor pathways from the ipsilesional M1, contralesional M1, to the affected limb. A step-wise linear regression model revealed these two brain reorganization patterns collaboratively contributed to FMA-UL improvement. In conclusion, MT achieved motor rehabilitation primarily by recruitment of the ipsilateral motor pathways. Trial Registration Information: http://www.chictr.org.cn. Unique Identifier. ChiCTR-INR-17013644, submitted on December 2, 2017.

Immersive virtual reality-based rehabilitation for subacute stroke: a randomized controlled trial

OBJECTIVE

Few effective treatments improve upper extremity (UE) function after stroke. Immersive virtual reality (imVR) is a novel and promising strategy for stroke UE recovery. We assessed the extent to which imVR-based UE rehabilitation can augment conventional treatment and explored changes in brain functional connectivity (FC) that were related to the rehabilitation.

METHODS

An assessor-blinded, parallel-group randomized controlled trial was performed with 40 subjects randomly assigned to either imVR or Control group (1:1 allocation), each receiving rehabilitation 5 times per week for 3 weeks. Subjects in the imVR received both imVR and conventional rehabilitation, while those in the Control received conventional rehabilitation only. Our primary and secondary outcomes were the Fugl-Meyer assessment's upper extremity subscale (FMA-UE) and the Barthel Index (BI), respectively. Both intention-to-treat (ITT) and per-protocol (PP) analyses were performed to assess the effectiveness of the trial. For both the FMA-UE/BI, a one-way analysis of covariance (ANCOVA) model was used, with the FMA-UE/BI at post-intervention or at follow-up, respectively, as the dependent variable, the two groups as the independent variable, baseline FMA-UE/BI, age, sex, site, time since onset, hypertension and diabetes as covariates.

RESULTS

Both ITT and PP analyses demonstrated the effectiveness of imVR-based rehabilitation. The FMA-UE score was greater in the imVR compared with the Control at the post-intervention (mean difference: 9.1 (95% CI 1.6, 16.6); P = 0.019) and follow-up (mean difference:11.5 (95% CI 1.9, 21.0); P = 0.020). The results were consistent for BI scores. Moreover, brain FC analysis found that the motor function improvements were associated with a change in degree in ipsilesional premotor cortex and ipsilesional dorsolateral prefrontal cortex immediately following the intervention and in ipsilesional visual region and ipsilesional middle frontal gyrus after the 12-week follow-up.

CONCLUSIONS

ImVR-based rehabilitation is an effective tool that can improve the recovery of UE functional capabilities of subacute stroke patients when added to standard care. These improvements were associated with distinctive brain changes at two post-stroke timepoints. The study results will benefit future patients with stroke and provide evidence for a promising new method of stroke rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03086889.

Detection of Rehabilitation Training Effect of Upper Limb Movement Disorder Based on MPL-CNN

Stroke represents a medical emergency and can lead to the development of movement disorders such as abnormal muscle tone, limited range of motion, or abnormalities in coordination and balance. In order to help stroke patients recover as soon as possible, rehabilitation training methods employ various movement modes such as ordinary movements and joint reactions to induce active reactions in the limbs and gradually restore normal functions. Rehabilitation effect evaluation can help physicians understand the rehabilitation needs of different patients, determine effective treatment methods and strategies, and improve treatment efficiency. In order to achieve real-time and accuracy of action detection, this article uses Mediapipe's action detection algorithm and proposes a model based on MPL-CNN. Mediapipe can be used to identify key point features of the patient's upper limbs and simultaneously identify key point features of the hand. In order to detect the effect of rehabilitation training for upper limb movement disorders, LSTM and CNN are combined to form a new LSTM-CNN model, which is used to identify the action features of upper limb rehabilitation training extracted by Medipipe. The MPL-CNN model can effectively identify the accuracy of rehabilitation movements during upper limb rehabilitation training for stroke patients. In order to ensure the scientific validity and unified standards of rehabilitation training movements, this article employs the postures in the Fugl-Meyer Upper Limb Rehabilitation Training Functional Assessment Form (FMA) and establishes an FMA upper limb rehabilitation data set for experimental verification. Experimental results show that in each stage of the Fugl-Meyer upper limb rehabilitation training evaluation effect detection, the MPL-CNN-based method's recognition accuracy of upper limb rehabilitation training actions reached 95%. At the same time, the average accuracy rate of various upper limb rehabilitation training actions reaches 97.54%. This shows that the model is highly robust across different action categories and proves that the MPL-CNN model is an effective and feasible solution. This method based on MPL-CNN can provide a high-precision detection method for the evaluation of rehabilitation effects of upper limb movement disorders after stroke, helping clinicians in evaluating the patient's rehabilitation progress and adjusting the rehabilitation plan based on the evaluation results. This will help improve the personalization and precision of rehabilitation treatment and promote patient recovery.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Systematic review registration

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

The use of home-based digital technology to support post-stroke upper limb rehabilitation: A scoping review

OBJECTIVE

To identify, map and synthesize the extent and nature of existing studies on the use of home-based digital technology to support post-stroke upper limb rehabilitation.

DATA SOURCES

A comprehensive literature search was completed between 30 May 2022 and 05 April 2023, from seven online databases (CINAHL, Cochrane Library, PubMed, ScienceDirect, IEEExplore, Web of Science and PEDro), Google Scholar and the reference lists of already identified articles.

METHODS

A scoping review was conducted according to Arksey and O'Malley (2005), and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. All English-language studies reporting on the use of home-based digital technology to support upper limb post-stroke rehabilitation were eligible for inclusion.

RESULTS

The search generated a total of 1895 records, of which 76 articles met the inclusion criteria. Of these, 52 were experimental studies and the rest, qualitative, case series and case studies. Of the overall 2149 participants, 2028 were stroke survivors with upper limb impairment. The majority of studies were aimed at developing, designing and/or assessing the feasibility, acceptability and efficacy of a digital system for poststroke upper limb rehabilitation in home settings. The thematic analysis found six major categories: Tele-rehabilitation (n = 29), games (n = 45), virtual reality (n = 26), sensor (n = 22), mobile technology (n = 22), and robotics (n = 8).

CONCLUSION

The digital technologies used in post-stroke upper limb rehabilitation were multimodal, and system-based comprising telerehabilitation, gamification, virtual reality, mobile technology, sensors and robotics. Furthermore, future research should focus to determine the effectiveness of these modalities.

Effects of Immersive Virtual Reality on Upper-Extremity Stroke Rehabilitation: A Systematic Review with Meta-Analysis

Virtual reality (VR) is an innovative rehabilitation tool increasingly used in stroke rehabilitation. Fully immersive VR is a type of VR that closely simulates real-life scenarios, providing a high level of immersion, and has shown promising results in improving rehabilitation functions. This study aimed to assess the effect of immersive VR-based therapy for stroke patients on the upper extremities, activities of daily living (ADLs), and pain reduction and its acceptability and side effects. For this review, we gathered all suitable randomized controlled trials from PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science. Out of 1532, 10 articles were included, with 324 participants. The results show that immersive VR offers greater benefits in comparison with conventional rehabilitation, with significant improvements observed in ADLs (SMD 0.58, 95% CI 0.25 to 0.91, I2 = 0%, p = 0.0005), overall function as measured by the Fugl-Meyer Assessment (MD 6.33, 95% CI 4.15 to 8.50, I2 = 25%, p = 0.00001), and subscales for the shoulder (MD 4.96, 95% CI-1.90-8.03, I2 = 25%, p = 0.002), wrist (MD 2.41, 95% CI-0.56-4.26, I2 = 0%, p = 0.01), and hand (MD 2.60, 95% CI-0.70-4.5°, I2 = 0%, p = 0.007). These findings highlight the potential of immersive VR as a valuable therapeutic option for stroke survivors, enhancing their ADL performance and upper-limb function. The immersive nature of VR provides an engaging and immersive environment for rehabilitation.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Research on Teleoperated Virtual Reality Human-Robot Five-Dimensional Collaboration System

In the realm of industrial robotics, there is a growing challenge in simplifying human-robot collaboration (HRC), particularly in complex settings. The demand for more intuitive teleoperation systems is on the rise. However, optimizing robot control interfaces and streamlining teleoperation remains a formidable task due to the need for operators to possess specialized knowledge and the limitations of traditional methods regarding operational space and time constraints. This study addresses these issues by introducing a virtual reality (VR) HRC system with five-dimensional capabilities. Key advantages of our approach include: (1) real-time observation of robot work, whereby operators can seamlessly monitor the robot's real-time work environment and motion during teleoperation; (2) leveraging VR device capabilities, whereby the strengths of VR devices are harnessed to simplify robot motion control, significantly reducing the learning time for operators; and (3) adaptability across platforms and environments: our system effortlessly adapts to various platforms and working conditions, ensuring versatility across different terminals and scenarios. This system represents a significant advancement in addressing the challenges of HRC, offering improved teleoperation, simplified control, and enhanced accessibility, particularly for operators with limited prior exposure to robot operation. It elevates the overall HRC experience in complex scenarios.

Virtual Reality Intervention and Its Impact on Upper Extremity Function in the Stroke Population: A Scoping Review

The aim of this scoping review was to examine virtual reality (VR) interventions used within rehabilitation and their effect on the functional outcomes of individuals with stroke. Specifically, this study sought to determine the impact of VR on the upper extremity (UE) use of participants as it relates to body function, occupational participation, and overall UE function (UEfxn). Twenty-six articles were selected for inclusion and results were extracted to determine common themes of outcomes among the effects of VR intervention (VRI). Thematic analysis included details about the VRIs used, as well as the change in UE outcomes post-VRI. Overall, positive change in UEfxn was found across many of the studies, indicating that VR technologies may be an effective intervention technique for individuals, poststroke. Findings of this review encourage clinicians to conduct further research regarding VR technology for UE rehabilitation poststroke.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Graph analysis of cortical reorganization after virtual reality-based rehabilitation following stroke: a pilot randomized study

Introduction

Stroke is the leading cause of functional disability worldwide. With the increase of the global population, motor rehabilitation of stroke survivors is of ever-increasing importance. In the last decade, virtual reality (VR) technologies for rehabilitation have been extensively studied, to be used instead of or together with conventional treatments such as physiotherapy or occupational therapy. The aim of this work was to evaluate the GestureCollection VR-based rehabilitation tool in terms of the brain changes and clinical outcomes of the patients.

Methods

Two groups of chronic patients underwent a rehabilitation treatment with (experimental) or without (control) complementation with GestureCollection. Functional magnetic resonance imaging exams and clinical assessments were performed before and after the treatment. A functional connectivity graph-based analysis was used to assess differences between the connections and in the network parameters strength and clustering coefficient.

Results

Patients in both groups showed improvement in clinical scales, but there were more increases in functional connectivity in the experimental group than in the control group.

Discussion

The experimental group presented changes in the connections between the frontoparietal and the somatomotor networks, associative cerebellum and basal ganglia, which are regions associated with reward-based motor learning. On the other hand, the control group also had results in the somatomotor network, in its ipsilateral connections with the thalamus and with the motor cerebellum, which are regions more related to a purely mechanical activity. Thus, the use of the GestureCollection system was successfully shown to promote neuroplasticity in several motor-related areas.

Limitations and solutions of low cost virtual reality mirror therapy for post-stroke patients

Mirror therapy is applied to reduce phantom pain and as a rehabilitation technique in post-stroke patients. Using Virtual Reality and head-mounted displays this therapy can be performed in virtual scenarios. However, for its efficient use in clinical settings, some hardware limitations need to be solved. A new system to perform mirror therapy in virtual scenarios for post-stroke patients is proposed. The system requires the patient a standalone virtual reality headset with hand-tracking features and for the rehabilitator an external computer or tablet device. The system provides functionalities for the rehabilitator to prepare and follow-up rehabilitation sessions and a virtual scenario for the patient to perform rehabilitation. The system has been tested on a real scenario with the support of three experienced rehabilitators and considering ten post-stroke patients in individual sessions focused on upper limb motor rehabilitation. The development team observed all the sessions and took note of detected errors regarding technological aspects. Solutions to solve detected problems will be proposed and evaluated in terms of feasibility, performance cost, additional system cost, number of solved issues, new limitations, or advantages for the patient. Three types of errors were detected and solved. The first error is related to the position of the hands relative to the head-mounted display. To solve it the exercise area can be limited to avoid objectives that require turning the head too far. The second error is related to the interaction between the hands and the virtual objects. It can be solved making the main hand non-interactive. The last type of error is due to patient limitations and can be mitigated by having a virtual hand play out an example motion to bring the patient's attention back to the exercise. Other solutions have been evaluated positively and can be used in addition or instead of the selected ones. For mirror therapy based on virtual reality to be efficient in post-stroke rehabilitation the current head-mounted display-based solutions need to be complemented with specific strategies that avoid or mitigate the limitations of the technology and the patient. Solutions that help with the most common issues have been proposed.

Structural and functional changes of the cerebellum in temporal lobe epilepsy

Aims

This study aimed to comprehensively explore the cerebellar structural and functional changes in temporal lobe epilepsy (TLE) and its association with clinical information.

Methods

The SUIT toolbox was utilized to perform cerebellar volume and diffusion analysis. In addition, we extracted the average diffusion values of cerebellar peduncle tracts to investigate microstructure alterations. Seed-based whole-brain analysis was used to investigate cerebellar-cerebral functional connectivity (FC). Subgroup analyses were performed to identify the cerebellar participation in TLE with/without hippocampal sclerosis (HS)/focal-to-bilateral tonic-clonic seizure (FBTCS) and TLE with different lateralization.

Results

TLE showed widespread gray matter atrophy in bilateral crusII, VIIb, VIIIb, left crusI, and left VIIIa. Both voxel and tract analysis observed diffusion abnormalities in cerebellar afferent peduncles. Reduced FC between the right crus II and the left parahippocampal cortex was found in TLE. Additionally, TLE showed increased FCs between left lobules VI-VIII and cortical nodes of the dorsal attention and visual networks. Across all patients, decreased FC was associated with poorer cognitive function, while increased FCs appeared to reflect compensatory effects. The cerebellar structural changes were mainly observed in HS and FBTCS subgroups and were regardless of seizure lateralization, while cerebellar-cerebral FC alterations were similar in all subgroups.

Conclusion

TLE exhibited microstructural changes in the cerebellum, mainly related to HS and FBTCS. In addition, altered cerebellar-cerebral functional connectivity is associated with common cognitive alterations in TLE.

Neurofunctional correlates of a neurorehabilitation system based on eye movements in chronic stroke impairment levels: A pilot study

INTRODUCTION

Rehabilitation after a stroke is widely considered fundamental to improve secondary functional impairments. Accessible methods based on motor learning, motor transfer and virtual environments are necessary to help to improve stroke patients' quality of life.

OBJECTIVES

Continuing the line of our previous studies, this work investigated the effect of our new and innovative game-based virtual reality training using the control of virtual objects with gaze in three chronic stroke survivors.

METHODS

All participants performed an eye-controlled virtual training task for 4 weeks. Pre- and post-training evaluation were carried out with the Fugl-Meyer Assessment for upper extremity scale as well as performing a tracking task inside an MRI scanner with a MRI-compatible eye-tracker or a joystick.

RESULTS

Neural results for each participant show the increase of activity in the motor cortex, basal ganglia and cerebellum for both effectors (hand or eye).

CONCLUSION

These promising results have a potential application as a new game-based neurorehabilitation approach to enhance the motor activity of stroke patients.

Comparison of Different Rehabilitation Techniques of Traditional Chinese and Western Medicine in the Treatment of Motor Dysfunction After Stroke Based on Frequency Method: A Network Meta-analysis

OBJECTIVE

The aim of the study is to evaluate the effect of different traditional Chinese and western medicine rehabilitation techniques on motor dysfunction after stroke using a network meta-analysis.

METHODS

CNKI, Wanfang, PubMed, Embase, and Cochrane databases were searched from inception to September 2022. We independently searched and screened randomized controlled trials of rehabilitation techniques for poststroke motor dysfunction treatment, evaluated the quality, and analyzed the data using Stata 14.0.

RESULTS

Seventy-four randomized controlled trials involving nine rehabilitation techniques and 5128 patients were included. The results of network meta-analysis showed the following orders regarding improvement of the total scores of Fugl-Meyer Assessment, Action Research Arm Test, and Berg Balance Scale: biofeedback therapy > mirror therapy > repetitive transcranial magnetic stimulation > acupuncture therapy > transcranial direct current stimulation > Taichi > common therapy, virtual reality > transcranial direct current stimulation > repetitive transcranial magnetic stimulation > mirror therapy > common therapy, and acupuncture therapy > virtual reality > neuromuscular electrical stimulation > mirror therapy > common therapy > transcranial direct current stimulation, respectively.

CONCLUSIONS

Biofeedback therapy had the best comprehensive effect, while virtual reality was the best intervention for improving the index of action research arm test and Fugl-Meyer Assessment-lower extremity. Acupuncture therapy improved lower limb balance function.

Effect of Physiotherapy Treatment with Immersive Virtual Reality in Subjects with Stroke: A Protocol for a Randomized Controlled Trial

BACKGROUND

Many stroke survivors suffer from sensorimotor deficits, especially balance impairments. The purpose of this trial is to investigate whether the designed Immersive Virtual Reality training program is better in the short term (15 sessions) and in the medium term (30 sessions) than physiotherapy training with Bayouk, Boucher and Leroux exercises, with respect to static balance in sitting and standing, dynamic balance and quality of life in patients with balance impairment in stroke survivors.

METHODS

This study is a randomized controlled trial with two treatment arms and evaluators blinded, and a functionality treatment group in combination with specific balance exercise training according to Bayouk, Boucher and Leroux (control group) or a balanced treatment using Immersive VR. The primary outcome will be static, Dynamic balance and gait measured by Bestest Assessment Score (BESTest), Berg Scale (BBS), Pass Scale (PASS) and Time Up and Go test (TUG). The secondary outcome will be the stroke-associated quality of life using the Stroke Quality of Life Scale (ECVI-38).

CONCLUSIONS

The results of this study may add new insights into how to address balance using Immersive Virtual Reality after a stroke. If the new training approach proves effective, the results may provide insight into how to design more comprehensive protocols in the future for people with balance impairments after stroke.

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

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

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

OBJECTIVE

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

DATA SOURCES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Relationship between Corticospinal Excitability While Gazing at the Mirror and Motor Imagery Ability

Mirror therapy (MT) helps stroke survivors recover motor function. Previous studies have reported that an individual's motor imagery ability is related to the areas of brain activity during motor imagery and the effectiveness of motor imagery training. However, the relationship between MT and motor imagery ability and between corticospinal tract excitability during mirror gazing, an important component of MT, and motor imagery ability is unclear. This study determined whether the motor-evoked potential (MEP) amplitude while gazing at the mirror relates to participants' motor imagery abilities. Twenty-four healthy right-handed adults (seven males) were recruited. Transcranial magnetic stimulation was performed while gazing at the mirror, and MEP of the first dorsal interosseous muscle of the right hand were measured. Motor imagery ability was measured using the Kinesthetic and Visual Imagery Questionnaire (KVIQ), which assesses the vividness of motor imagery ability. Additionally, a mental chronometry (MC) task was used to assess time aspects. The results showed a significant moderate correlation between changes in MEP amplitude values while gazing at the mirror, as compared with resting conditions, and assessment scores of KVIQ. This study shows that corticospinal excitability because of mirror gazing may be related to the vividness of motor imagery ability.

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

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

Immersive Virtual Reality in Post-Stroke Rehabilitation: A Systematic Review

In recent years, next to conventional rehabilitation's techniques, new technologies have been applied in stroke rehabilitation. In this context, fully immersive virtual reality (FIVR) has showed interesting results thanks to the level of immersion of the subject in the illusional world, with the feeling of being a real part of the virtual environment. This study aims to investigate the efficacy of FIVR in stroke rehabilitation. PubMed, Web of Science and Scopus were screened up to November 2022 to identify eligible randomized controlled trials (RCTs). Out of 4623, we included 12 RCTs involving post-acute and chronic stroke survivors, with a total of 350 patients (234 men and 115 women; mean age 58.36 years). High heterogeneity of the outcomes considered, the results showed that FIVR provides additional benefits, in comparison with standard rehabilitation. In particular, results showed an improvement in upper limb dexterity, gait performance and dynamic balance, influencing patient independence. Therefore, FIVR represents an adaptable, multi-faceted rehabilitation tool that can be considered in post-stroke rehabilitation, improving the compliance of the patients to the treatment and increasing the level of functioning and quality of life of stroke survivors.

Virtual reality does not fool the brain only: spinal excitability changes during virtually simulated falling

Virtual reality (VR) is known to induce substantial activation of brain's motor regions. It remains unclear to what extent virtual reality can trigger the sensorimotor system, and more particularly, whether it can affect lower nervous levels. In this study, we aimed to assess whether VR simulation of challenging and stressful postural situations (Richie's plank experience) could interfere with spinal excitability of postural muscles in 15 healthy young participants. The H-reflex of the triceps surae muscles was elicited with electrical nerve stimulation while participants were standing and wearing a VR headset. Participants went through several conditions, during which stimulations were evoked: standing still (noVR), standing in VR on the ground (groundVR), standing on the edge of a building (plankVR), and falling from the building (fallingVR). Myoelectrical activity of the triceps surae muscles was measured throughout the experiment. Leg and head movements were also measured by means of accelerometers to account for body oscillations. First, no differences in head rotations and myoelectrical activity were to be noted between conditions. Second, triceps H-reflex (H_MAX/M_MAX) was not affected from noVR to groundVR and plankVR. The most significant finding was a drastic decrease in H-reflex during falling (-47 ± 26.9% between noVR and fallingVR, P = 0.015). It is suggested that experiencing a postural threat in VR efficiently modulates spinal excitability, despite remaining in a quiet standing posture. This study suggests that simulated falling mimics the neural adjustments observed during actual postural challenge tasks.NEW & NOTEWORTHY The present study showed a modulation of spinal excitability induced by virtual reality (VR). In the standing position, soleus H-reflex was downmodulated during a simulated falling, in the absence of apparent changes in body oscillations. Since the same behavior is usually observed during real falling, it was suggested that the visual cues provided by VR were sufficiently strong to lead the neuromuscular system to mimic the actual modulation.

Home-based immersive virtual reality physical rehabilitation in paediatric patients for upper limb motor impairment: a feasibility study

Upper limb motor impairment (ULMI) rehabilitation is a long-term, demanding and challenging process to recover motor functionality. Children and adolescents may be limited in daily life activities due to reduced functions such as decreased joint movement or muscle weakness. Home-based therapy with Immersive Virtual Reality can offer greater accessibility, delivery and early rehabilitation to significantly optimise functional outcomes and quality of life. This feasibility study aimed to explore the perceptions and impacts of an immersive and interactive VR scenario suitable for ULMI rehabilitation for children at home. It was analysed using mixed methods (quantitative and qualitative) and from a multidirectional perspective (patients, clinicians and family members). Amongst the main results, it was found that IVR for ULMI home rehabilitation (1) is easy to learn and acceptable; (2) improves motor function; (3) reduces the difficulty in the reproduction of therapeutic movements; (4) is motivating and enjoyable and (5) improves quality of life. This study is the first study on the use of IVR applied to home rehabilitation of ULMI in children. These results suggested that similar outcomes may be possible with self-directed IVR home rehabilitation compared to face to face conventional rehabilitation, which can be costly to both the patient and the healthcare system, decreasing the length of stay at the hospital and treatment duration. It has also presented an innovative solution to the Covid-19 emergency where children could not receive their clinic therapy. Further research is recommended to understand better the mechanisms involved in physiotherapeutic recovery and how IVR rehabilitation helps to improve conventional treatments. Trial Registration Protocol ID NCT05272436. Release Date: 9th March 2022.

Virtual reality-induced motor function of the upper extremity and brain activation in stroke: study protocol for a randomized controlled trial

Background

The benefits of virtual reality (VR)-based rehabilitation were reported in patients after stroke, but there is insufficient evidence about how VR promotes brain activation in the central nervous system. Hence, we designed this study to explore the effects of VR-based intervention on upper extremity motor function and associated brain activation in stroke patients.

Methods/design

In this single-center, randomized, parallel-group clinical trial with a blinded assessment of outcomes, a total of 78 stroke patients will be assigned randomly to either the VR group or the control group. All stroke patients who have upper extremity motor deficits will be tested with functional magnetic resonance imaging (fMRI), electroencephalography (EEG), and clinical evaluation. Clinical assessment and fMRI will be performed three times on each subject. The primary outcome is the change in performance on the Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE). Secondary outcomes are functional independence measure (FIM), Barthel Index (BI), grip strength, and changes in the blood oxygenation level-dependent (BOLD) effect in the ipsilesional and contralesional primary motor cortex (M1) on the left and right hemispheres assessed with resting-state fMRI (rs-fMRI), task-state fMRI (ts-fMRI), and changes in EEG at the baseline and weeks 4 and 8.

Discussion

This study aims to provide high-quality evidence for the relationship between upper extremity motor function and brain activation in stroke. In addition, this is the first multimodal neuroimaging study that explores the evidence for neuroplasticity and associated upper motor function recovery after VR in stroke patients.

Clinical trial registration

Chinese Clinical Trial Registry, identifier: ChiCTR2200063425.

Immersion Therapy with Head-Mounted Display for Rehabilitation of the Upper Limb after Stroke-Review

Immersive virtual therapy technology is a new method that uses head-mounted displays for rehabilitation purposes. It offers a realistic experience that puts the user in a virtual reality. This new type of therapy is used in the rehabilitation of stroke patients. Many patients after this disease have complications related to the upper extremities that limit independence in their everyday life, which affects the functioning of society. Conventional neurological rehabilitation can be supplemented by the use of immersive virtual therapy. The system allows patients with upper limb dysfunction to perform a motor and task-oriented training in virtual reality that is individually tailored to their performance. The complete immersion therapy itself is researched and evaluated by medical teams to determine the suitability for rehabilitation of the upper limb after a stroke. The purpose of this article is to provide an overview of the latest research (2019-2022) on immersive virtual reality with head-mounted displays using in rehabilitation of the upper extremities of stroke patients.

Feasibility and psychophysical effects of immersive virtual reality-based mirror therapy

Background

Virtual reality (VR) has been used as a technological medium to deliver mirror therapy interventions with people after stroke in numerous applications with promising results. The recent emergence of affordable, off-the-shelf head-mounted displays (like the Oculus Rift or HTC Vive) has opened the possibility for novel and cost-effective approaches for immersive mirror therapy interventions. We have developed one such system, ART-VR, which allows people after stroke to carry out a clinically-validated mirror therapy protocol in an immersive virtual environment and within a clinical setting.

Methods

A case cohort of 11 people with upper limb paresis following first time stroke at an in-patient rehabilitation facility received three interventions over a one week period. Participants carried out the BeST mirror therapy protocol using our immersive VR system as an adjunct therapy to their standard rehabilitation program. Our clinical feasibility study investigated intervention outcomes, virtual reality acceptance and user experience.

Results

The results show that the combination of an immersive VR system and mirror therapy protocol is feasible for clinical use. 9 out of 11 participants showed some improvement of their affected hand after the intervention. The vast majority of the participants (9/11) reported experiencing some psycho-physical effects, such as tingling or paraesthesia, in the affected limb during the intervention.

Conclusions

Our findings show that immersive VR-based mirror therapy is feasible and shows effects comparable to those of conventional mirror therapy.

Trial Registration Trial was registered with the ISRCTN Registry (ISRCTN34011164) on December 3, 2021, retrospectively

Rapid assessment of hand reaching using virtual reality and application in cerebellar stroke

The acquisition of sensory information about the world is a dynamic and interactive experience, yet the majority of sensory research focuses on perception without action and is conducted with participants who are passive observers with very limited control over their environment. This approach allows for highly controlled, repeatable experiments and has led to major advances in our understanding of basic sensory processing. Typical human perceptual experiences, however, are far more complex than conventional action-perception experiments and often involve bi-directional interactions between perception and action. Innovations in virtual reality (VR) technology offer an approach to close this notable disconnect between perceptual experiences and experiments. VR experiments can be conducted with a high level of empirical control while also allowing for movement and agency as well as controlled naturalistic environments. New VR technology also permits tracking of fine hand movements, allowing for seamless empirical integration of perception and action. Here, we used VR to assess how multisensory information and cognitive demands affect hand movements while reaching for virtual targets. First, we manipulated the visibility of the reaching hand to uncouple vision and proprioception in a task measuring accuracy while reaching toward a virtual target (n = 20, healthy young adults). The results, which as expected revealed multisensory facilitation, provided a rapid and a highly sensitive measure of isolated proprioceptive accuracy. In the second experiment, we presented the virtual target only briefly and showed that VR can be used as an efficient and robust measurement of spatial memory (n = 18, healthy young adults). Finally, to assess the feasibility of using VR to study perception and action in populations with physical disabilities, we showed that the results from the visual-proprioceptive task generalize to two patients with recent cerebellar stroke. Overall, we show that VR coupled with hand-tracking offers an efficient and adaptable way to study human perception and action.

The effectiveness of immersive virtual reality in physical recovery of stroke patients: A systematic review

Background

Over the past few years, technological innovations have been increasingly employed to augment the rehabilitation of stroke patients. Virtual reality (VR) has gained attention through its ability to deliver a customized training session and to increase patients' engagement. Virtual reality rehabilitation programs allow the patient to perform a therapeutic program tailored to his/her needs while interacting with a computer-simulated environment.

Purpose

This study aims to investigate the effectiveness of a fully immersive rehabilitation program using a commercially available head-mounted display in stroke patients.

Methods

A systematic search was conducted in three databases, namely, PubMed, Google Scholar, and PEDro. Four hundred thirty-two references were identified. The keywords used for the literature search were in English, which are given as follows: immersive, virtual reality, neurorehabilitation, stroke, and head-mounted display. Additionally, applicable articles were identified through screening reference lists of relevant articles.

Results

Only 12 studies used head-mounted display for immersing the patient into the virtual world. Apart from the feasibility of this new technology, a range of benefits were identified, especially in terms of functional ability as measured by FIM or Barthel, the Action Research arm Test, Box and Block Test, Fugl-Meyer assessment of physical performance, strength, and balance outcomes.

Conclusion

The results from this review support the potential beneficial effect of fully immersive virtual reality in the rehabilitation of stroke patients, maximizing recovery through increased motivation and adherence.

Activity of Mirror Neurons and Its Effect on Various Diseases

Ayna nöronların nöroanatomik yapılanması ve işlevselliğinin araştırılması son yıllarda oldukça artmıştır. Özellikle nörolojik ve ortopedik hasta gruplarında uygulanan tedavi yaklaşımlarında pasif uygulamalar yerine hastanın katılımının olduğu aktif uygulamalar tercih edilmektedir. Bunun temel sebeplerinden birisi ayna nöronları ve birincil motor korteksi dâhil ederek tedaviyi kalıcı hale getirmeyi amaçlamaktır. Ayna nöronların fonksiyonel ve disfonksiyonel durumlarını ortaya koymak, tedavi seanslarında hastaların semptomlarını anlamada çok büyük katkı sağlamaktadır. Özellikle ayna nöronları aktive ederek planlanan ayna terapisi ile hastalar nöronal bağlantılarını yeniden yapılandırarak nöroplastik aktivite sağlarlar ve böylece iyileşme süreçlerine katkıda bulunmuş olurlar. Literatür taramalarında ayna nöronların aktivasyonlarının yer aldığı hastalıkların yapısal özellikleri birbirinden farklı olsa da ortak özellik olarak ayna nöronların aktive edilerek tedaviye katkı sağladığını söylemek mümkündür. Yapılan tedavi uygulamalarında, ilgili fonksiyonel hareketin hasta tarafından fiziksel olarak yapılmadığı durumlarda dahi bilişsel olarak hareketin yapıldığının imgelenmesi, ayna nöronları aktive ederek hastanın iyilik halini arttırdığı belirlenmiştir. 

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

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

Recent trends in telerehabilitation of stroke patients: A narrative review

BACKGROUND: Stroke is the main reason for disabilities worldwide leading to motor dysfunction, spatial neglect and cognitive problems, aphasia, and other speech-language pathologies, reducing the life quality. To overcome disabilities, telerehabilitation (TR) has been recently introduced. OBJECTIVE: The aim of this review was to analyze current TR approaches for stroke patients’ recovery. METHODS: We searched 6 online databases from January 2018 to October 2021, and included 70 research and review papers in the review. We analyzed TR of 995 individuals, which was delivered synchronously and asynchronously. RESULTS: Findings show TR is feasible improving motor function, cognition, speech, and language communication among stroke patients. However, the dose of TR sessions varied significantly. We identified the following limitations: lack of equipment, software, and space for home-based exercises, insufficient internet capacity and speed, unavailability to provide hands on guidance, low digital proficiency and education, high cognitive demand, small samples, data heterogeneity, and no economic evaluation. CONCLUSIONS: The review shows TR is superior or similar to conventional rehabilitation in clinical outcomes and is used as complementary therapy or as alternative treatments. More importantly, TR provides access to rehabilitation services of a large number of patients with immobility, living in remote areas, and during COVID-19 pandemic or similar events.

New technologies promoting active upper limb rehabilitation after stroke: an overview and network meta-analysis

INTRODUCTION

The primary aim of this work was to summarize and compare the effects of active rehabilitation assisted by new technologies (virtual reality [VR], robot-assisted therapy [RAT] and telerehabilitation [TR)) on upper limb motor function and everyday living activity during the subacute and chronic phases of stroke. The secondary aims were to compare the effects of these technologies according to the intervention design (in addition to or in substitution of conventional therapy), the duration of active rehabilitation and the severity of patients' motor impairments.

EVIDENCE ACQUISITION

Several databases, namely PubMed, Scopus, Embase and Cochrane Library, were searched. Studies were included if they were meta-analyses with a moderate to high level of confidence (assessed with AMSTAR-2) that compared the effects of a new technology promoting active rehabilitation to that of a conventional therapy program among patients with stroke. Network meta-analyses were conducted to compare the effects of the new technologies.

EVIDENCE SYNTHESIS

Eighteen different meta-analyses were selected and fifteen included in the quantitative analysis. In total these 15 meta-analyses were based on 189 different randomized controlled trials. VR (SMD≥0.25; P<0.05), RAT (SMD≥0.29; P≤0.29) and TR (SMD≥-0.08; P≤0.64) were found to be at least as effective as conventional therapy. During the subacute phase, RAT's greatest effect was observed for patients with severe-moderate impairments whereas VR and TR's greatest effects were observed for patients with mild impairments. During the chronic phase, the highest effects were observed for patients with mild impairments, for all studies technologies. Network meta-analyses showed that VR and RAT were both significantly superior to TR in improving motor function during the chronic phase but revealed no significant difference between VR, RAT and TR effectiveness on both motor function (during the subacute phase) and activity (during both chronic and subacute phase).

CONCLUSIONS

This overview provides low-to-moderate evidence that rehabilitation assisted with technologies are at least as effective as conventional therapy for patients with stroke. While VR and RAT seem to be more efficient during the subacute phase, all technologies seem to be as efficient as one another in the chronic phase.

Bioinspired Stretchable Fiber-Based Sensor toward Intelligent Human-Machine Interactions

Wearable integrated sensing devices with flexible electronic elements exhibit enormous potential in human-machine interfaces (HMI), but they have limitations such as complex structures, poor waterproofness, and electromagnetic interference. Herein, inspired by the profile of Lindernia nummularifolia (LN), a bionic stretchable optical strain (BSOS) sensor composed of an LN-shaped optical fiber incorporated with a stretchable substrate is developed for intelligent HMI. Such a sensor enables large strain and bending angle measurements with temperature self-compensation by the intensity difference of two fiber Bragg gratings' (FBGs') center wavelength. Such configurations enable an excellent tensile strain range of up to 80%, moreover, leading to ultrasensitivity, durability (≥20,000 cycles), and waterproofness. The sensor is also capable of measuring different human activities and achieving HMI control, including immersive virtual reality, robot remote interactive control, and personal hands-free communication. Combined with the machine learning technique, gesture classification can be achieved using muscle activity signals captured from the BSOS sensor, which can be employed to obtain the motion intention of the prosthetic. These merits effectively indicate its potential as a solution for medical care HMI and show promise in smart medical and rehabilitation medicine.

Virtual Reality in Clinical Practice and Research: Viewpoint on Novel Applications for Nursing

Virtual reality is a novel technology that provides users with an immersive experience in 3D virtual environments. The use of virtual reality is expanding in the medical and nursing settings to support treatment and promote wellness. Nursing has primarily used virtual reality for nursing education, but nurses might incorporate this technology into clinical practice to enhance treatment experience of patients and caregivers. Thus, it is important for nurses to understand what virtual reality and its features are, how this technology has been used in the health care field, and what future efforts are needed in practice and research for this technology to benefit nursing. In this article, we provide a brief orientation to virtual reality, describe the current application of this technology in multiple clinical scenarios, and present implications for future clinical practice and research in nursing.

Virtual Reality in the Neurosciences: Current Practice and Future Directions

Virtual reality has made numerous advancements in recent years and is used with increasing frequency for education, diversion, and distraction. Beginning several years ago as a device that produced an image with only a few pixels, virtual reality is now able to generate detailed, three-dimensional, and interactive images. Furthermore, these images can be used to provide quantitative data when acting as a simulator or a rehabilitation device. In this article, we aim to draw attention to these areas, as well as highlight the current settings in which virtual reality (VR) is being actively studied and implemented within the field of neurosurgery and the neurosciences. Additionally, we discuss the current limitations of the applications of virtual reality within various settings. This article includes areas in which virtual reality has been used in applications both inside and outside of the operating room, such as pain control, patient education and counseling, and rehabilitation. Virtual reality's utility in neurosurgery and the neurosciences is widely growing, and its use is quickly becoming an integral part of patient care, surgical training, operative planning, navigation, and rehabilitation.

Effects of virtual reality-based motor rehabilitation: a systematic review of fMRI studies

BACKGROUND

The use of virtual reality (VR) as a rehabilitation tool has been shown to induce motor and cognitive improvements in different populations. Functional magnetic resonance imaging (fMRI) has been used to investigate neuroplasticity resulting from these treatments. We hypothesize that VR rehabilitation induces functional improvement and brain changes that can be detected by fMRI.

OBJECTIVE

To systematically review the effects of VR intervention on the cortical reorganization measured by fMRI and associated with functional improvement.

METHODS

We performed a systematic review of studies published between 2005 and 2021. Papers were retrieved from six databases using the following keywords: "motor rehabilitation", "fMRI" and "virtual reality". Case studies, pre-post studies, cross-sectional studies, and randomized controlled trials published were included. Manuscripts were assessed by The NIH Study Quality Assessment Tools to determine their quality.

RESULTS

Twenty-three articles met our eligibility criteria: 18 about VR rehabilitation in stroke and five on other clinical conditions (older adults, cerebral palsy, and Parkinson's disease). Changes in neural patterns of activation and reorganization were revealed in both the ipsilesional and the contralesional hemispheres. Results were located mainly in the primary motor cortex, sensorimotor cortex and supplementary motor area in post-stroke patients in the acute, subacute, and chronic rehabilitation phases, and were associated with functional improvement after VR intervention. Similar effects were observed in older adults and in patients with other neurological diseases with improved performance.

CONCLUSION

Most stroke-related studies showed either restoration to normal or increase of activation patterns or relateralization at/to the ipsilesional hemisphere, with some also reporting a decrease in activity or extent of activation after VR therapy. In general, VR intervention demonstrated evidence of efficacy both in neurological rehabilitation and in performance improvement of older adults, accompanied by fMRI evidence of brain reorganization.

Effects of virtual reality in improving upper extremity function after stroke: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the effect of virtual reality on arm motor impairment, activity limitation, participation restriction, and quality of life in patients with stroke. To determine potential moderators that affect the efficacy of virtual reality.

DATA SOURCES

CINAHL, Medline, PubMed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang Data from inception to October 23, 2021.

REVIEW METHODS

Randomized controlled trials that investigated the effect of virtual reality on arm recovery in adult patients with stroke compared to conventional therapy or sham control were included. Physiotherapy Evidence Database Scale was used to assess the methodological quality of each study.

RESULTS

Forty studies with 2018 participants were identified. Quality of included studies was fair to high. Virtual reality exhibited better effects on overall arm function (g = 0.28, p < 0.001), motor impairment (g = 0.36, p < 0.001) and activity limitation (daily living) (g = 0.24, p < 0.001) compared with the control group. No significant improvement was observed in participation restriction and activity limitation (specific task). The result for quality of life was described qualitatively. Subgroup analyses demonstrated that immersive virtual reality produced a greater beneficial effect (g = 0.60, p < 0.001). Patients with moderate to severe arm paresis could make more progress after training (g = 0.71, p < 0.001).

CONCLUSION

Virtual reality is recommended for improving motor impairment and activities of daily living after stroke and is favorable to patients with moderate to severe paresis. An immersive design could produce greater improvement.

Effects of Virtual Reality-Based Intervention on Cognition, Motor Function, Mood, and Activities of Daily Living in Patients With Chronic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: The efficacy of virtual reality (VR)-based intervention for improving cognition in patients with the chronic stage of stroke is controversial. The aims of this meta-analysis were to evaluate the effect of VR-based training combined with traditional rehabilitation on cognition, motor function, mood, and activities of daily living (ADL) after chronic stroke. Methods: The search was performed in the Cochrane Library (CENTRAL), EBSCO, EMBASE, Medline (OVID), Web of Science databases, PubMed, CINAHL Ovid, and Scopus from inception to May 31, 2021. All included studies were randomized controlled trials (RCTs) examining VR-based intervention combined with traditional rehabilitation for chronic stroke. The main outcomes of this study were cognition, including overall cognition (combined with all cognitive measurement results), global cognition (measured by the Montreal Cognitive Assessment, MoCA, and/or Mini-Mental State Examination, MMSE), and attention/execution. The additional outcomes were motor function, mood, and ADL. Subgroup analyses were conducted to verify the potential factors for heterogeneity. Results: Six RCTs including 209 participants were included for systematic review, and five studies of 177 participants were included in meta-analyses. Main outcome analyses showed large and significant effect size (ES) of VR-based training on overall cognition (g = 0.642; 95% CI = 0.134-1.149; and P = 0.013) and attention/execution (g = 0.695; 95% CI = 0.052-1.339; and P = 0.034). Non-significant result was found for VR-based intervention on global cognition (g = 0.553; 95% CI = -0.273-1.379; and P = 0.189). Additional outcome analyses showed no superiority of VR-based intervention over traditional rehabilitation on motor function and ADL. The ES of VR-based intervention on mood (g = 1.421; 95% CI = 0.448-2.393; and P = 0.004) was large and significant. In the subgroup analysis, large effects for higher daily intensity, higher weekly frequency, or greater dose of VR intervention were found. Conclusion: Our findings indicate that VR-based intervention combined with traditional rehabilitation showed better outcomes for overall cognition, attention/execution, and depressive mood in individuals with chronic stroke. However, VR-based training combined with traditional rehabilitation showed a non-significant effect for global cognition, motor function, and ADL in individuals with chronic stroke.

Effect of Time-Dose-Matched Virtual Reality Therapy on Upper Limb Dysfunction in Patients Poststroke: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To investigate the efficacy and acceptability of virtual reality (VR) with time-dose-matched conventional therapy (CT) in patients poststroke with upper limb dysfunction.

DATA SOURCES

Cochrane, PubMed, Web of Science, Embase, and ProQuest were systematically searched up to May 24, 2021.

STUDY SELECTION

Randomized controlled trials comparing VR with time-dose-matched CT in patients poststroke with upper limb dysfunction were included.

DATA EXTRACTION

The extracted data included efficacy (mean change in structure/function, activity, and participation scores), acceptability (dropouts for all reasons), adverse events, and characteristics of the included studies. The Cochrane risk of bias assessment tool was used to assess the risk of bias.

DATA SYNTHESIS

Thirty-one randomized controlled trails were included. VR was superior to time-dose-matched CT in terms of the World Health Organization's International Classification of Functioning, Disability and Health structure/function, with a standardized mean difference (SMD) of 0.35, but not activity and participation. Subgroup analyses demonstrated that virtual environment was superior to CT in structure/function (SMD=0.38) and activity (SMD=0.27), whereas there were no significant differences between commercial gaming and CT in any World Health Organization International Classification of Functioning, Disability and Health domain. VR mixed with CT was more effective than time-dose-matched CT in structure/function (SMD=0.56), whereas VR only was not significantly different from CT. There were no significant differences in the incidence of adverse events and dropout rates between VR and CT.

CONCLUSIONS

The results suggest that VR is superior to time-dose-matched CT in terms of recovery of upper extremity motor function, especially when a virtual environment is used or VR is mixed with CT. However, VR (VR only or mixed with CT) does not improve patients' daily activity performance and participation compared with CT. Overall, VR appears to be safe and acceptable as CT. Large-scale definitive trials are needed to verify or refute these findings.

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.