Rehabilitation of children with hemiparesis: a pilot study on the use of virtual reality

TABLET TOSCANA to Develop Innovative Organizational Models for Tele-Rehabilitation in Subjects with Congenital and Acquired Developmental Disabilities: A Wait-List Control Group Trial Protocol

Background/Objectives: In recent years, the advent of new technologies has fostered their application in neuro-psychomotor and language rehabilitation, particularly since the COVID-19 pandemic. Tele-rehabilitation has emerged as an innovative and timely solution, enabling personalized interventions monitored by clinicians. TABLET TOSCANA project aims to develop innovative tele-rehabilitation organizational models in children, adolescents and young adults with congenital and acquired developmental disabilities, using the Virtual Reality Rehabilitation System (VRRS) Home Kit and the MedicoAmico APP. Methods: The trial is designed according to the CONSORT statement guidelines. The project encompasses three phases: adapting the technologies for pediatric use, validating them through a wait-list study, and analyzing feasibility and effectiveness data to define new organizational models. A randomized wait-list-control study with 100 subjects aged 6 to 30 years will compare tele-rehabilitation versus prosecution of standard care. Discussion: Although literature highlights tele-rehabilitation benefits such as improved access, cost savings, and enhanced treatment adherence, practical implementation remains limited (i.e., the definition of standardized procedures). TABLET TOSCANA project seeks to address these gaps by focusing on multi-domain treatments for neurodevelopmental disabilities and emphasizing the integration of tele-rehabilitation into local health services. Conclusion: The project aims to improve the continuity and intensity of care through innovative models that integrate tele-rehabilitation into local health services. The results could inform healthcare policies and promote the development of innovative and collaborative models of care, paving the way for more effective and widespread tele-rehabilitation solutions and fostering collaborative networks among professionals.

Quantifying patient experiences with therapeutic neurorehabilitation technologies: a scoping review

PURPOSE

Neurorehabilitation technologies are a novel approach to providing rehabilitation for patients with neurological conditions. There is a need to explore patient experiences. This study aimed; 1) To identify available questionnaires that assess patients' experiences with neurorehabilitation technologies, and 2) where reported, to document the psychometric properties of the identified questionnaires.

MATERIALS AND METHODS

Four databases were searched (Medline, Embase, Emcare and PsycInfo). The inclusion criteria were all types of primary data collection that included neurological patients of all ages who had experienced therapy with neurorehabilitation technologies and completed questionnaires to assess these experiences.

RESULTS

Eighty-eight publications were included. Fifteen different questionnaires along with many self-developed scales were identified. These were categorised as; 1) self-developed tools, 2) specific questionnaire for a particular technology, and 3) generic questionnaires originally developed for a different purpose. The questionnaires were used to assess various technologies, including virtual reality, robotics, and gaming systems. Most studies did not report any psychometric properties.

CONCLUSION

Many tools have been used to evaluate patient experiences, but few were specifically developed for neurorehabilitation technologies and psychometric data was limited. A preliminary recommendation would be use of the User Satisfaction Evaluation Questionnaire to evaluate patient experience with virtual reality systems.

Assessment of Postural Control in Children with Movement Disorders by Means of a New Technological Tool: A Pilot Study

Considering the variability and heterogeneity of motor impairment in children with Movement Disorders (MDs), the assessment of postural control becomes essential. For its assessment, only a few tools objectively quantify and recognize the difference among children with MDs. In this study, we use the Virtual Reality Rehabilitation System (VRRS) for assessing the postural control in children with MD. Furthermore, 16 children (mean age 10.68 ± 3.62 years, range 4.29-18.22 years) were tested with VRRS by using a stabilometric balance platform. Postural parameters, related to the movements of the Centre of Pressure (COP), were collected and analyzed. Three different MD groups were identified according to the prevalent MD: dystonia, chorea and chorea-dystonia. Statistical analyses tested the differences among MD groups in the VRRS-derived COP variables. The mean distance, root mean square, excursion, velocity and frequency values of the dystonia group showed significant differences (p < 0.05) between the chorea group and the chorea-dystonia group. Technology provides quantitative data to support clinical assessment: in this case, the VRRS detected differences among the MD patterns, identifying specific group features. This tool could be useful also for monitoring the longitudinal trajectories and detecting post-treatment changes.

A narrative review of the use of a cutting-edge virtual reality rehabilitation technology in neurological and neuropsychological rehabilitation

BACKGROUND

Virtual reality (VR) interventions have been increasingly used in the rehabilitation of a wide range of neurological and neuropsychological dysfunctions. Findings of previous reviews showed positive and promising effects of VR-based interventions. However, they summarized findings on VR-based intervention carried out through different VR systems and tasks.

OBJECTIVE

We carried out a narrative review with the aim of qualitatively synthesising the results of previous studies that used specific VR systems, i.e. the Khymeia -Virtual Reality Rehabilitation System, for treatment purposes.

METHODS

We searched the literature in various databases (i.e. EMBASE, Web of Science, SCOPUS, PubMed and PubMed Central) for studies published until November 23, 2023.

RESULTS

30 studies were selected. The VRRS was used for neuromotor rehabilitation only in 13 studies, for cognitive rehabilitation in 11 studies, and for both neuromotor and cognitive rehabilitation in six studies. The study design was heterogeneous including 15 randomised controlled trials.

CONCLUSION

After discussing each study according to the type of rehabilitation we concluded that the use and efficacy of VRRS rehabilitative intervention for increasing the neurological and neuropsychological functioning of patients are promising but more evidence is needed to make a comparison with conventional treatment. Future studies should also include long-term follow-up as well as cost-effectiveness analysis.

Pediatric Patients With Hemiplegia: A Systematic Review of a Randomized Controlled Trial

Hemiplegia is the medical term for paralysis of one side of the body. It results in muscular wasting on the affected side, impairs gait, reduces motor abilities, and causes instability and a loss of grasping capacity. The patient's quality of life is impacted by hemiplegia because it impairs brain and spinal cord functions. Consequently, a range of therapeutic options, including physical therapy, medical health management, and other multidisciplinary care, are accessible. The effects of treatments on juvenile patients with hemiplegia who are participating in a randomized controlled trial (RCT) are examined in this systematic review. Using the Boolean operator "AND," the research process entailed searching for keywords like "Hemiplegia" and "Pediatrics." Based on the inclusion and exclusion criteria, a total of six RCTs were included in the study. According to the study's findings, hemiplegic patients benefited from Kinesio taping (KT), botulinum toxin type-A (BoNT-A), hyaluronic acid injections, and bimanual treatment.

Italian, European, and international neuroinformatics efforts: An overview

Neuroinformatics is a research field that focusses on software tools capable of identifying, analysing, modelling, organising and sharing multiscale neuroscience data. Neuroinformatics has exploded in the last two decades with the emergence of the Big Data phenomenon, characterised by the so-called 3Vs (volume, velocity and variety), which provided neuroscientists with an improved ability to acquire and process data faster and more cheaply thanks to technical improvements in clinical, genomic and radiological technologies. This situation has led to a 'data deluge', as neuroscientists can routinely collect more study data in a few days than they could in a year just a decade ago. To address this phenomenon, several neuroimaging-focussed neuroinformatics platforms have emerged, funded by national or transnational agencies, with the following goals: (i) development of tools for archiving and organising analytical data (XNAT, REDCap and LabKey); (ii) development of data-driven models evolving from reductionist approaches to multidimensional models (RIN, IVN, HBD, EuroPOND, E-DADS and GAAIN BRAIN); and (iii) development of e-infrastructures to provide sufficient computational power and storage resources (neuGRID, HBP-EBRAINS, LONI and CONP). Although the scenario is still fragmented, there are technological and economical attempts at both national and international levels to introduce high standards for open and Findable, Accessible, Interoperable and Reusable (FAIR) neuroscience worldwide.

Does Non-Immersive Virtual Reality Improve Attention Processes in Severe Traumatic Brain Injury? Encouraging Data from a Pilot Study

Traumatic brain injury (TBI) is a sudden injury that causes damage to the brain. Rehabilitation therapies include specific training, such as attention process training (APT) programs using either standard or innovative approaches. The aim of this study is to evaluate the effects of a non-immersive virtual reality-based attention training to stimulate attention processes and mood in TBI patients. Thirty subjects with TBI were enrolled at the Neurorehabilitation Unit of the IRCCS Neurolesi Center and divided into either the Conventional Attention Process Training Group (C_APT: n = 15) or the Virtual-Based Attention Processes Training Group (VB_APT: n = 15), treated with the Virtual Reality Rehabilitation System (VRRS-Evo). All of the patients were evaluated with a specific psychometric battery before (T0) and after the end (T1) of each program. We found statistically significant differences between the two groups, in particular concerning global cognitive status (p < 0.02), attention processes (p < 0.03), depression symptoms (p < 0.04) and visual attention (p < 0.01). Experimental intragroup analysis showed great statistical significances in all psychometric tests, i.e., the Montreal Cognitive Assessment (p < 0.0006), Attention Matrices (p < 0.0007), the Hamilton Rating Scale-Depression (p < 0.004), the Trail Making Test-A (p < 0.0007), the Trail Making Test-B (p < 0.0007), and the Trail Making test-BA (p < 0.007). Our results suggest that non-immersive virtual reality may be a useful and effective approach for the attention processes recovery and mood of TBI patients, leading to better cognitive and behavioral outcomes.

New Technological Approach for the Evaluation of Postural Control Abilities in Children with Developmental Coordination Disorder

Background: Developmental Coordination Disorder (DCD) causes difficulties in postural control which are crucial to assess due to their impact on everyday life. There is a lack of suitable tools to acquire quantitative data and deeply analyze postural control, especially during the developmental age. The aim of this study is to investigate postural control skills in children with DCD and typically developing children (TD) using the Virtual Reality Rehabilitation System (VRRS). Methods: 18 children with DCD and 30 TD children (mean age 9.12 ± 2.65 and 7.12 ± 2.77 years, respectively) were tested by using the Movement Assessment Battery for Children Second Edition (MABC-2) and a VRRS stabilometric balance platform. A t-test was performed to identify differences in the VRRS parameters between the two groups. Furthermore, we investigated whether a correlation exists between the VRRS data and the MABC-2. Results: Significant differences (p < 0.05) in mean distance and frequency of the COP are found in the two groups. These parameters also correlate with the MABC-2 total score (p ≤ 0.05) and balance subscales (p ≤ 0.05). Conclusions: This study opens a new frontier for the assessment of postural skills in children with DCD and represents a potential basis for a tailored rehabilitation program, from which their postural stability and, consequently, their everyday life will benefit.

Application of Virtual Reality Rehabilitation System for the assessment of postural control while standing in typical children and peers with neurodevelopmental disorders

BACKGROUND

The assessment of postural control in children is crucial, due to its central role in their overall development. However, a tool that objectively quantifies the difference in postural control between typical and atypical developing children is lacking. In this study, we introduce a new technology (Virtual Reality Rehabilitation System, VRRS) for assessing children's postural control.

RESEARCH QUESTION

Is this new assessment tool capable to highlight the differences between typical development (TD) and atypical development, (children with Developmental Coordination Disorder (DCD) and Cerebral Palsy (CP))?

METHODS

30 TD children, 20 children with DCD and 27 with CP (mean ages: 6.29 ± 2.74; 9.11 ± 2.65; 10.07 ± 3.89 years) were tested with the VRRS Tablet with stabilometric balance platform. Postural parameters, related to the movements of the Centre of Pressure (COP) were collected. A multivariate analysis of variance (MANOVA) followed by a post-hoc analysis has been carried out. Moreover, the influence of age, sex, clinical scores and sub-diagnoses on parameters of interest has been explored.

RESULTS

COP distance and sway area in the three groups (TD: 7.35 ± 2.32 mm, 101.70 ± 64.16 mm²/s; DCD: 12.05 ± 8.19 mm, 188.46 ± 231.23 mm²/s; CP: 13.25 ± 8.09 mm, 239.13 ± 313.83 mm²/s, respectively) and all other VRRS parameters were significantly different among the three groups (p-values between 0.028 and <0.001). The TD group showed significantly different values than CP (p from < 0.03 to < 0.001) but not than DCD (p = n.s.). Clinical scores showed to correlate with the COP distances and Root Mean Square distances in all subgroups (p < 0.05). For age, only an influence was found within the TD group (p < 0.01); sex did not show to affect the outcomes (p = n.s.).

SIGNIFICANCE

An objective tool for quantitative measurement of postural control in childhood is needed. Our proposed VRRS tool could support the traditional assessment tests, highlighting differences between typical and atypical development.

Tele-Rehabilitation for Postural Control by Means of Virtual Reality Rehabilitation System in an Adolescent With Motor Disorder: A Case Study

The coming of an unforeseen and hostile event such as the COVID-19 pandemic has brought about various changes in everyone's daily life. During the lockdown period, a huge number of restrictions were imposed, hence interrupting a wide range of activities previously proven to be necessary for some people. Due to the circumstances, rehabilitation treatments for children with neurodevelopmental disorders have been suspended, resulting in consequent distress for the children themselves and their parents. To overcome this problem, a tele-rehabilitation approach has proven to be an excellent solution to give continuity to children's rehabilitation. The tele-rehabilitation approach allows access to rehabilitation services directly from home. During lockdown due to the COVID-19 pandemic, the Virtual Reality Rehabilitation System (VRRS) HomeKit, developed by Khymeia, was employed as a rehabilitation system for the treatment of posture and balance of an adolescent with disabilities for the first time ever. Specifically, a 17-year-old female patient was enrolled and evaluated by the clinical staff before and after the home-training sessions. The system was delivered to the patient's home so that she could perform the tasks in a familiar environment, while under the supervision of the clinical staff. Through a specific platform, using different modules of the system, therapists could remotely check that the proposed exercises were properly performed and provide feedback and/or increase the difficulty according to the patient's needs and progress. Therefore, the treatment performed was carried out at home in a personalized, intensive, and playful way; characteristics do not present in a traditional treatment. Our results are promising and demonstrate both the efficacy of rehabilitation exercises carried out at home and the feasibility of home-based rehabilitation, when using the VRRS HomeKit even with adolescents. The VRRS HomeKit presents some limitations, such as the need to have the line connection and free space at home, the presence of technical issues, and the education of parents and patients to understand the instructions. Despite the limitations, this study provides the basis for continuing the experience of tele-rehabilitation on patients with a motor disorder also by customizing the exercises to their characteristics.

Conventional and Virtual Reality Mirror Therapies in Upper Obstetric Brachial Palsy: A Randomized Pilot Study

The abilities of children diagnosed with Obstetric Brachial Palsy (OBP) are limited by brachial plexus injuries. Thus, their participation in the community is hindered, which involves a lower quality of life due to worse performance in activities of daily living as a consequence of the functional limitations of the affected upper limb. Conventional Mirror Therapy (Conventional MT) and Virtual Therapy improve the affected upper limb functionality. Therefore, the aim of this study was to compare the effects of Conventional MT and Virtual Reality MT on the spontaneous use of the affected upper limb and quality of life of children with upper Obstetric Brachial Palsy between 6 and 12 years of age. A randomized pilot study was performed. Twelve children were randomly assigned to perform Conventional Mirror Therapy or Virtual Reality Mirror Therapy for four weeks. Ten children completed the treatment. Two assessments (pre/post-intervention) were carried out to assess the spontaneous use of the affected upper limb and the quality of life using the Children’s Hand-use Experience Questionnaire (CHEQ) and the Pediatric Quality of Life Inventory Generic Core Scales (PedsQL TM 4.0), respectively. There was a statistically significant increment in spontaneous use, observed in independent tasks (p = 0.02) and in the use of the affected hand with grasp (p = 0.04), measured with the CHEQ, for the Virtual Reality MT group. There were no statistically significant changes (p > 0.05) for the Conventional MT group in the spontaneous use of the affected upper limb. Regarding the quality of life, statistically significant changes were obtained in the Physical and Health activity categories of the parents’ questionnaire (p = 0.03) and in the total score of the children’s questionnaire (p = 0.04) in the Virtual Reality MT group, measured using the PedsQL TM 4.0. Statistically significant changes were not obtained for the quality of life in the Conventional MT group. This study suggests that, compared to Conventional MT, Virtual Reality MT would be a home-based therapeutic complement to increase independent bimanual tasks using grasp in the affected upper limb and improve the quality of life of children diagnosed with upper OBP in the age range of 6–12 years.

Validity and Reliability of a Virtual Reality Game in Evaluating the Projected Frontal Plane Knee Angle When Landing From a Drop Vertical Jump

OBJECTIVES

To determine the validity and reliability of the peak frontal plane knee angle evaluated by a virtual reality (VR) netball game when landing from a drop vertical jump.

STUDY DESIGN

Laboratory.

METHODS

Forty participants performed 3 drop vertical jumps evaluated by 3-dimensional motion analysis and 3 drop vertical jumps evaluated by the VR game. Limits of agreement for the peak projected frontal plane knee angle and peak knee abduction were determined. Participants were given a consensus category of "above threshold" or "below threshold" based on a prespecified threshold angle of 9° during landing. Classification agreement was determined using kappa coefficient, and accuracy was determined using specificity and sensitivity. Ten participants returned 1 week later to determine intrarater reliability, standard error of the measure, and typical error.

RESULTS

The mean difference in detected frontal plane knee angle was 3.39° (95% confidence interval [CI], 1.03° to 5.74°). Limits of agreement were -10.27° (95% CI, -14.36° to -6.19°) to 17.05° (95% CI, 12.97° to 21.14°). Substantial agreement, specificity, and sensitivity were observed for the threshold classification (κ = .66; 95% CI, .42 to .88; specificity = 0.96; 95% CI, 0.78 to 1.0; and sensitivity = 0.75; 95% CI, 0.43 to 0.95). The game exhibited acceptable reliability over time (intraclass correlation coefficient, ICC3,1 = .844), and error was approximately 2°.

CONCLUSION

The VR game reliably evaluated a projected frontal plane knee angle. Although the knee angle detected by the VR game is strongly related to peak knee abduction, the accuracy of detecting the exact angle was limited. A threshold approach may be a more accurate approach for gaming technology to evaluate frontal plane knee angles when landing from a jump.

Computer Assisted REhabilitation (CARE) Lab: A novel approach towards Pediatric Rehabilitation 2.0

Pediatric Rehabilitation therapists have always worked using a variety of off-the-shelf or custom-made objects and devices, more recently including computer based systems. These Information and Communication Technology (ICT) solutions vary widely in complexity, from easy-to-use interactive videogame consoles originally intended for entertainment purposes to sophisticated systems specifically developed for rehabilitation.This paper describes the principles underlying an innovative "Pediatric Rehabilitation 2.0" approach, based on the combination of suitable ICT solutions and traditional rehabilitation, which has been progressively refined while building up and using a computer-assisted rehabilitation laboratory. These principles are thus summarized in the acronym EPIQ, to account for the terms Ecological, Personalized, Interactive and Quantitative. The paper also presents the laboratory, which has been designed to meet the children's rehabilitation needs and to empower therapists in their work. The laboratory is equipped with commercial hardware and specially developed software called VITAMIN: a virtual reality platform for motor and cognitive rehabilitation.