Correlation between MOVA3D, a Monocular Movement Analysis System, and Qualisys Track Manager (QTM) during Lower Limb Movements in Healthy Adults: A Preliminary Study

New technologies based on virtual reality and augmented reality offer promising perspectives in an attempt to increase the assessment of human kinematics. The aim of this work was to develop a markerless 3D motion analysis capture system (MOVA3D) and to test it versus Qualisys Track Manager (QTM). A digital camera was used to capture the data, and proprietary software capable of automatically inferring the joint centers in 3D and performing the angular kinematic calculations of interest was developed for such analysis. In the experiment, 10 subjects (22 to 50 years old), 5 men and 5 women, with a body mass index between 18.5 and 29.9 kg/m2, performed squatting, hip flexion, and abduction movements, and both systems measured the hip abduction/adduction angle and hip flexion/extension, simultaneously. The mean value of the difference between the QTM system and the MOVA3D system for all frames for each joint angle was analyzed with Pearson's correlation coefficient (r). The MOVA3D system reached good (above 0.75) or excellent (above 0.90) correlations in 6 out of 8 variables. The average error remained below 12° in only 20 out of 24 variables analyzed. The MOVA3D system is therefore promising for use in telerehabilitation or other applications where this level of error is acceptable. Future studies should continue to validate the MOVA3D as updated versions of their software are developed.

Comparison of Smoothness, Movement Speed and Trajectory during Reaching Movements in Real and Virtual Spaces Using a Head-Mounted Display

Virtual reality is used in rehabilitation and training simulators. However, whether movements in real and virtual spaces are similar is yet to be elucidated. The study aimed to examine the smoothness, trajectory, and velocity of participants' movements during task performance in real and virtual space. Ten participants performed the same motor task in these two spaces, reaching for targets placed at six distinct positions. A head-mounted display (HMD) presented the virtual space, which simulated the real space environment. The smoothness of movements during the task was quantified and analysed using normalised jerk cost. Trajectories were analysed using the actual trajectory length normalised by the shortest distance to the target, and velocity was analysed using the time of peak velocity. The analysis results showed no significant differences in smoothness and peak velocity time between the two spaces. No significant differences were found in the placement of the six targets between the two spaces. Conversely, significant differences were observed in trajectory length ratio and peak velocity time, albeit with small effect sizes. This outcome can potentially be attributed to the fact that the virtual space was presented from a first-person perspective using an HMD capable of presenting stereoscopic images through binocular parallax. Participants were able to obtain physiological depth information and directly perceive the distance between the target and the effector, such as a hand or a controller, in virtual space, similar to real space. The results suggest that training in virtual space using HMDs with binocular disparity may be a useful tool, as it allows the simulation of a variety of different environments.

Will Your Next Therapist Be a Robot?-A Review of the Advancements in Robotic Upper Extremity Rehabilitation

Several recent studies have indicated that upper extremity injuries are classified as a top common workplace injury. Therefore, upper extremity rehabilitation has become a leading research area in the last few decades. However, this high number of upper extremity injuries is viewed as a challenging problem due to the insufficient number of physiotherapists. With the recent advancements in technology, robots have been widely involved in upper extremity rehabilitation exercises. Although robotic technology and its involvement in the rehabilitation field are rapidly evolving, the literature lacks a recent review that addresses the updates in the robotic upper extremity rehabilitation field. Thus, this paper presents a comprehensive review of state-of-the-art robotic upper extremity rehabilitation solutions, with a detailed classification of various rehabilitative robots. The paper also reports some experimental robotic trials and their outcomes in clinics.

The design, delivery and evaluation of 'Human Perspectives VR': An immersive educational programme designed to raise awareness of contributory factors for a traumatic childbirth experience and PTSD

BACKGROUND

A traumatic childbirth experience affects ~30% of women each year, with negative impacts on maternal, infant, and family wellbeing. Women classified as vulnerable or marginalised are those more likely to experience a psychologically traumatising birth. A key contributory factor for a traumatic childbirth experience is women's relationships with maternity care providers.

AIMS

To develop, design and evaluate an immersive educational programme for maternity care providers to raise awareness of traumatic childbirth experiences amongst vulnerable groups, and ultimately to improve women's experiences of childbirth.

METHODS

A critical pedagogical approach that utilised virtual reality (VR) underpinned the design and development of the educational programme. This involved: a) collecting vulnerable/disadvantaged women's experiences of birth via interviews; b) analysing data collected to identify key hotspots for traumatic experiences within interpersonal patient-provider relationships to develop a script; c) filming the script with professional actors creating a first person perspective via VR technology; d) using existing literature to inform the theoretical and reflective aspects of the programme; e) conducting an evaluation of the education programme using pre-and post-evaluation questionnaires and a follow-up focus group.

FINDINGS

Human Perspective VR was very well received. Participants considered the content to have enhanced their reflective practice and increased their knowledge base regarding contributory factors associated with a traumatic childbirth experience. A need for further work to implement learning into practice was highlighted.

CONCLUSION

While further research is needed to evaluate the impact of the programme, Human Perspective VR programme offers an innovative approach to reflective education and to enhance participants' care practices.

The effect of attentional focus on movement accuracy in an immersive and interactive virtual reality environment

The effects of attentional focus (AF) instruction were examined in a reciprocal aiming task implemented in a 3-dimensional, fully immersive virtual environment (VE). Within the VE, participants (N = 19) moved a cube between two targets at two paces (750 ms and 500 ms) while being asked to focus externally (EXF) and internally (INF). Performance accuracy was measured as two-dimensional error and its variability between the center of the target to the center of the cube and one-dimensional bias (undershooting/overshooting behavior in the anteroposterior and mediolateral directions). The results indicated better performance, specifically greater accuracy and lower one-dimensional bias in the anteroposterior direction when adopting an EXF compared to an INF. Our findings reveal that the beneficial effects of an EXF on motor performance are not restricted movements within physical environments only but also work in VE. This has implications for rehabilitation and training protocols in VE.

Kinematic Validity of Reaching in a 2D Virtual Environment for Arm Rehabilitation After Stroke

Increasing evidence supports the use of virtual reality for stroke rehabilitation. However, movement performance and quality may be diminished by the attributes of the virtual environment (VE), which may be detrimental to motor relearning. Our aim was to determine whether reach-to-grasp movements made in a low-cost 2DVE were kinematically similar to those made in a comparable physical environment (PE) in healthy subjects and subjects with stroke. Subjects (healthy = 15, stroke = 22) made unilateral and bilateral reach-to-grasp movements in a 2DVE and a similar PE. Arm and trunk kinematics were recorded with an optoelectronic measurement system (23 markers; 120 Hz). Temporal and spatial characteristics of the endpoint trajectory, arm and trunk movement patterns were compared between environments and groups. In each group, hand positioning at object contact time and trunk displacement were unaffected by the environment. Compared to PE, in VE, unilateral movements were less smooth and time to peak velocity was prolonged. In healthy subjects, bilateral movements were simultaneous and symmetrical in both environments. In subjects with stroke, movements were less symmetrical in VE. Aside from differences in endpoint displacement between environments, movement quality variables were unaffected by the 2DVE. Thus, using a low-cost 2DVE may be a valid approach for sensorimotor rehabilitation following stroke.

Technology-assisted rehabilitation following total knee or hip replacement for people with osteoarthritis: a systematic review and meta-analysis

BACKGROUND

To evaluate the effectiveness and safety of technology-assisted rehabilitation following total hip/knee replacement (THR/TKR).

METHODS

Six electronic databases were searched without language or time restrictions for relevant studies: MEDLINE, EMBASE, Cochrane Library, CINAHL, SPORTDiscus, Physiotherapy Evidence Database (PEDro); from inception to November 7th, 2018. Two reviewers independently applied inclusion criteria to select eligible randomised controlled trials (RCTs) that investigated the effectiveness of technology-based interventions, compared with usual care or no intervention for people undergoing THR/TKR. Two reviewers independently extracted trial details (e.g. patients' profile, intervention, outcomes, attrition and adverse events). Study methodological quality was assessed using the PEDro scale. Quality of evidence was critically appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

We identified 21 eligible studies assessing telerehabilitation, game- or web-based therapy. There were 17 studies (N = 2188) in post-TKR rehabilitation and 4 studies (N = 783) in post-THR rehabilitation. Compared to usual care, technology-based intervention was more effective in reducing pain (mean difference (MD): - 0.25; 95% confidence interval (CI): - 0.48, - 0.02; moderate evidence) and improving function measured with the timed up-and-go test (MD: -7.03; 95% CI: - 11.18, - 2.88) in people undergoing TKR. No between-group differences were observed in rates of hospital readmissions or treatment-related adverse events (AEs) in those studies.

CONCLUSION

There is moderate-quality of evidence showed technology-assisted rehabilitation, in particular, telerehabilitation, results in a statistically significant improvement in pain; and low-quality of evidence for the improvement in functional mobility in people undergoing TKR. The effects were however too small to be clinically significant. For THR, there is very limited low-quality evidence shows no significant effects.

Tracking the evolution of virtual reality applications to rehabilitation as a field of study

Background

Application of virtual reality (VR) to rehabilitation is relatively recent with clinical implementation very rapidly following technological advancement and scientific discovery. Implementation is often so rapid that demonstrating intervention efficacy and establishing research priorities is more reactive than proactive. This study used analytical tools from information science to examine whether application of VR to rehabilitation has evolved as a distinct field of research or is primarily a methodology in core disciplines such as biomedical engineering, medicine and psychology.

Methods

The analysis was performed in three-stages: 1) a bibliographic search in the ISI Web of Science database created an initial corpus of publications, 2) the corpus was refined through topic modeling, and 3) themes dominating the corpus from the refined search results were identified by topic modeling and network analytics. This was applied separately to each of three time periods: 1996 to 2005 (418 publications), 2006 to 2014 (1454 publications), and 2015 to mid-2018 (1269 publications).

Results

Publication rates have continuously increased across time periods with principal topics shifting from an emphasis on computer science and psychology to rehabilitation and public health. No terminology specific to the field of VR-based rehabilitation emerged; rather a range of central concepts including “virtual reality”, “virtual gaming”, “virtual environments”, “simulated environments” continue to be used. Communities engaged in research or clinical application of VR form assemblages distinguished by a focus on physical or psychological rehabilitation; these appear to be weakly linked through tele-rehabilitation.

Conclusions

Varying terms exemplify the main corpus of VR-based rehabilitation and terms are not consistent across the many scientific domains. Numerous distinguishable areas of research and clinical foci (e.g., Tele-rehabilitation, Gait & Balance, Cognitive Rehabilitation, Gaming) define the agenda. We conclude that VR-based rehabilitation consists of a network of scientific communities with a shared interest in the methodology rather than a directed and focused research field. An interlinked team approach is important to maintain scientific rigor and technological validity within this diverse group. Future studies should examine how these interdisciplinary communities individually define themselves with the goals of gathering knowledge and working collectively toward disseminating information essential to associated research communities.

The Effects of a 5-Day Virtual-Reality Based Exercise Program on Kinematics and Postural Muscle Activity in Youth with Cerebral Palsy

Aims: To determine the effects of a 5-day virtual reality (VR)-based intervention on anticipatory and reactive mechanisms of postural control in children and adolescents with cerebral palsy (CP). Methods: Eleven youth with CP (GMFCS levels I and II), ages 7-17, were allocated to intervention (N = 5) and control (N = 6) groups. Both groups attended balance assessment sessions 1 week apart. Participants in the intervention group received 1-hour one-on-one physiotherapist-supervised VR balance games for 5 consecutive days between assessments. For balance assessments, participants stood erect with eyes open on a movable platform that translated progressively through four speeds in the anterior/posterior direction. Participants performed two trials each of experimenter-triggered and self-triggered perturbations. Postural muscle activity and kinematics were recorded. The Anchoring Index and body segment cross-correlations were calculated as an indication of body stabilization, and the number of steps taken to regain balance/avoid falling were counted. Mann-Whitney U tests for between group differences in change scores were undertaken with an accepted significance level of 0.01. Results: No consistent differences in change scores were identified between groups. Conclusions: There was no effect of a 5-day VR-based intervention on postural control mechanisms used in response to oscillating platform perturbations. Subsequent studies will further tailor VR interventions to patients' functional balance needs.

What is the level of evidence for the use of currently available technologies in facilitating the self-management of difficulties associated with ADHD in children and young people? A systematic review

A number of technologies to help self-manage attention deficit hyperactivity disorder (ADHD) in children and young people (YP) have been developed. This review will assess the level of evidence for the use of such technologies. The review was undertaken in accordance with the general principles recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. 7545 studies were screened. Fourteen studies of technology that aim to self-manage difficulties associated with ADHD in children and YP were included. Primary outcome measures were measures that assessed difficulties related to ADHD. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, the Cochrane Library, ProQuest ASSIA, PsycINFO and Scopus. The methodological quality of the studies was assessed. This review highlights the potential for the use of technology in paediatric ADHD management. However, it also demonstrates that current research lacks robustness; using small sample sizes, non-validated outcome measures and little psychoeducation component. Future research is required to investigate the value of technology in supporting children and YP with ADHD and a focus psychoeducation is needed.

Virtual Rehabilitation with Children: Challenges for Clinical Adoption [From the Field]

Virtual, augmented, and mixed reality environments are increasingly being developed and used to address functional rehabilitation goals related to physical, cognitive, social, and psychological impairments. For example, a child with an acquired brain injury may participate in virtual rehabilitation to address impairments in balance, attention, turn taking, and engagement in therapy. The trend toward virtual rehabilitation first gained momentum with the adoption of commercial off-the-shelf active video gaming consoles (e.g., Nintendo Wii and XBox). Now, we are seeing the rapid emergence of customized rehabilitation-specific systems that integrate technological advances in virtual reality, visual effects, motion tracking, physiological monitoring, and robotics.

A Telerehabilitation System for the Selection, Evaluation and Remote Management of Therapies

Telerehabilitation systems that support physical therapy sessions anywhere can help save healthcare costs while also improving the quality of life of the users that need rehabilitation. The main contribution of this paper is to present, as a whole, all the features supported by the innovative Kinect-based Telerehabilitation System (KiReS). In addition to the functionalities provided by current systems, it handles two new ones that could be incorporated into them, in order to give a step forward towards a new generation of telerehabilitation systems. The knowledge extraction functionality handles knowledge about the physical therapy record of patients and treatment protocols described in an ontology, named TrhOnt, to select the adequate exercises for the rehabilitation of patients. The teleimmersion functionality provides a convenient, effective and user-friendly experience when performing the telerehabilitation, through a two-way real-time multimedia communication. The ontology contains about 2300 classes and 100 properties, and the system allows a reliable transmission of Kinect video depth, audio and skeleton data, being able to adapt to various network conditions. Moreover, the system has been tested with patients who suffered from shoulder disorders or total hip replacement.

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

BACKGROUND

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

PURPOSE

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

METHOD

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

FINDINGS

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

IMPLICATIONS

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

Camera-tracking gaming control device for evaluation of active wrist flexion and extension

STUDY DESIGN

Cross sectional.

INTRODUCTION

Measuring wrist range of motion (ROM) is an essential procedure in hand therapy clinics.

PURPOSE OF THE STUDY

To test the reliability and validity of a dynamic ROM assessment, the Camera Wrist Tracker (CWT).

METHODS

Wrist flexion and extension ROM of 15 patients with distal radius fractures and 15 matched controls were assessed with the CWT and with a universal goniometer.

RESULTS

One-way model intraclass correlation coefficient analysis indicated high test-retest reliability for extension (ICC = 0.92) and moderate reliability for flexion (ICC = 0.49). Standard error for extension was 2.45° and for flexion was 4.07°. Repeated-measures analysis revealed a significant main effect for group; ROM was greater in the control group (F[1, 28] = 47.35; P < .001). The concurrent validity of the CWT was partially supported.

CONCLUSION

The results indicate that the CWT may provide highly reliable scores for dynamic wrist extension ROM, and moderately reliable scores for flexion, in people recovering from a distal radius fracture.

LEVEL OF EVIDENCE

N/A.

Music Games: Potential Application and Considerations for Rhythmic Training

Rhythmic skills are natural and widespread in the general population. The majority can track the beat of music and move along with it. These abilities are meaningful from a cognitive standpoint given their tight links with prominent motor and cognitive functions such as language and memory. When rhythmic skills are challenged by brain damage or neurodevelopmental disorders, remediation strategies based on rhythm can be considered. For example, rhythmic training can be used to improve motor performance (e.g., gait) as well as cognitive and language skills. Here, we review the games readily available in the market and assess whether they are well-suited for rhythmic training. Games that train rhythm skills may serve as useful tools for retraining motor and cognitive functions in patients with motor or neurodevelopmental disorders (e.g., Parkinson's disease, dyslexia, or ADHD). Our criteria were the peripheral used to capture and record the response, the type of response and the output measure. None of the existing games provides sufficient temporal precision in stimulus presentation and/or data acquisition. In addition, games do not train selectively rhythmic skills. Hence, the available music games, in their present form, are not satisfying for training rhythmic skills. Yet, some features such as the device used, the interface or the game scenario provide good indications for devising efficient training protocols. Guidelines are provided for devising serious music games targeting rhythmic training in the future.

Relationship between perceived competence and performance during real and virtual motor tasks by children with developmental coordination disorder

PURPOSE

(i) To compare children with DCD and typically developing participants via standard motor assessments, two interactive virtual games, measures of physical, social and cognitive self-competence and feedback while playing the virtual games and (ii) To examine the contribution of age and each motor assessment to predict self-competence.

METHODS

Participants were 25 boys with DCD and 25 typically developing boys, aged 5-9 years. They completed the M-ABC-2, the Pictorial Scale of Perceived Competence, the 6-Minute Walk Test, and then played the two Kinect games and completed the Short Feedback Questionnaire for Children.

RESULTS

Children with DCD showed lower physical competence and lower performance than the typical controls in all standard motor assessments. This performance significantly correlated with the children achievements in part of virtual games and with their self-perceived experience while performing within virtual environments. Among the DCD group, Kinect Running game significantly predicted physical and social competence.

CONCLUSIONS

The significant correlations between the virtual games and standard motor assessments support the feasibility of using these games when evaluating children with DCD for the richer profile they provide. Implications for rehabilitation Clinicians should refer to the impacts of DCD on child's self-competence and daily life. Technological rehabilitation and the use of VR games have the potential to improve self-competence of children with DCD. By including VR games that simulate real life in the intervention for DCD, clinicians may raise child's enjoyment, self-competence and involvement in therapy.

The use and effect of video game design theory in the creation of game-based systems for upper limb stroke rehabilitation

Upper limb exercise is often neglected during post-stroke rehabilitation. Video games have been shown to be useful in providing environments in which patients can practise repetitive, functionally meaningful movements, and in inducing neuroplasticity. The design of video games is often focused upon a number of fundamental principles, such as reward, goals, challenge and the concept of meaningful play, and these same principles are important in the design of games for rehabilitation. Further to this, there have been several attempts for the strengthening of the relationship between commercial game design and rehabilitative game design, the former providing insight into factors that can increase motivation and engagement with the latter. In this article, we present an overview of various game design principles and the theoretical grounding behind their presence, in addition to attempts made to utilise these principles in the creation of upper limb stroke rehabilitation systems and the outcomes of their use. We also present research aiming to move the collaborative efforts of designers and therapists towards a model for the structured design of these games and the various steps taken concerning the theoretical classification and mapping of game design concepts with intended cognitive and motor outcomes.

Differences in autonomic functions as related to induced stress between children with and without cerebral palsy while performing a virtual meal-making task

BACKGROUND

Efforts to improve the participation and performance of children with cerebral palsy (CP) are often related to the adaptation of environmental conditions to meet their cognitive and motor abilities. However, the influence of affective stimuli within the environment on emotion and performance, and their ability to improve or impede the children's participation has not been investigated in any systematic way although the emerging evidence suggests that it affects the individuals in many levels.

OBJECTIVES

(1) To measure autonomic responses to affective stimuli during a simulated Meal-Maker task in children with CP in comparison to children who are typically developing, and (2) to examine the interactions between autonomic functions, subjective reports of stress, and task performance among children with and without CP.

METHODS

Fifteen children with CP and 19 typically developing peers (6 to 12 years) participated. After completing behavioral questionnaires (e.g., State and Trait Anxiety Inventories), children prepared meals within a camera tracking virtual Meal-Maker environment. Either a negative, positive, or neutral visual stimulus was displayed, selected from the International Affective Picture System. Children also passively viewed the same pictures while rating their valence and arousal levels. Heart rate (HR) and skin conductance were recorded synchronously with stimulus onset.

RESULTS

Significant differences in autonomic functions were found between groups, i.e., a higher "low frequency" to "high frequency" (LF:HF) ratio in the children with CP during the meals associated with a negative stimulus (p=0.011). Only children with CP had significant positive correlations between trait anxiety and LF:HF ratio during virtual meal-making associated with positive (p=0.049) and negative stimuli (p=0.003) but not during neutral stimuli. For children with CP the amplitude of skin conductance response during passive picture viewing was significantly higher for negative than for positive stimuli (p=0.017) but there were no significant changes in autonomic responses during virtual Meal-Maker task. Significant correlations between trait anxiety, autonomic activity during the calm state and Meal-Maker performance outcomes were found only for children with CP.

CONCLUSIONS

In general, the Meal-Maker virtual environment was shown to be a feasible platform for the investigation of the effect of emotionally loaded stimuli on the balance of autonomic functions in children with and without CP. Anxiety level appears to play a significant role in children with CP and should be considered as a potentially important factor during clinical evaluation and intervention. Further studies are needed to develop additional measurements of emotional responses and to refine the types of affective interference.

Evaluating change in virtual reality adoption for brain injury rehabilitation following knowledge translation

PURPOSE

To evaluate the impact of knowledge translation (KT) on factors influencing virtual reality (VR) adoption and to identify support needs of therapists.

HYPOTHESES

Intervention will be associated with improvements in therapists' perceived ease of use and self-efficacy, and an associated increase in intentions to use VR.

METHOD

Single group mixed-methods pre-test-post-test evaluation of convenience sample of physical, occupational and rehabilitation therapists (n=37) from two brain injury rehabilitation centres. ADOPT-VR administered pre/post KT intervention, consisting of interactive education, clinical manual, technical and clinical support.

RESULTS

Increases in perceived ease of use (p=0.000) and self-efficacy (p=0.001), but not behavioural intention to use VR (p=0.158) were found following KT, along with decreases in the frequency of perceived barriers. Post-test changes in the frequency and nature of perceived facilitators and barriers were evident, with increased emphasis on peer influence, organisational-level supports and client factors. Additional support needs were related to clinical reasoning, treatment programme development, technology selection and troubleshooting.

CONCLUSIONS

KT strategies hold potential for targeting therapists' perceptions of low self-efficacy and ease of use of this technology. Changes in perceived barriers, facilitators and support needs at post-test demonstrated support for repeated evaluation and multi-phased training initiatives to address therapists' needs over time. Implications for Rehabilitation Therapists' learning and support needs in integrating virtual reality extend beyond technical proficiency to include clinical decision-making and application competencies spanning the entire rehabilitation process. Phased, multi-faceted strategies may be valuable in addressing therapists' changing needs as they progress from novice to experienced virtual reality users. The ADOPT-VR is a sensitive measure to re-evaluate the personal, social, environmental, technology-specific and system-level factors influencing virtual reality adoption over time.

A virtual shopping task for the assessment of executive functions: Validity for people with stroke

The importance of assessing executive functions (EF) using ecologically valid assessments has been discussed extensively. Due to the difficulty of carrying out such assessments in real-world settings on a regular basis, virtual reality has been proposed as a technique to provide complex functional tasks under a variety of differing conditions while measuring various aspects of performance and controlling for stimuli. The main goal of this study was to examine the discriminant, construct-convergent and ecological validity of the Adapted Four-Item Shopping Task, an assessment of the Instrumental Activity of Daily Living (IADL) of shopping. Nineteen people with stroke, aged 50-85 years, and 20 age- and gender-matched healthy participants performed the shopping task in both the SeeMe Virtual Interactive Shopping environment and a real shopping environment (the hospital cafeteria) in a counterbalanced order. The shopping task outcomes were compared to clinical measures of EF. The findings provided good initial support for the validity of the Adapted Four-Item Shopping Task as an IADL assessment that requires the use of EF for people with stroke. Further studies should examine this task with a larger sample of people with stroke as well as with other populations who have deficits in EF.

Validation of a Kinect-based telerehabilitation system with total hip replacement patients

The evolving telecommunications industry combined with medical information technology has been proposed as a solution to reduce health care cost and provide remote medical services. This paper aims to validate and show the feasibility and user acceptance of using a telerehabilitation system called Kinect Rehabilitation System (KiReS) in a real scenario, with patients attending repeated rehabilitation sessions after they had a Total Hip Replacement (THR). We present the main features of KiReS, how it was set up in the considered scenario and the experimental results obtained in relation to two different perspectives: patients' subjective perceptions (gathered through questionnaires) and the accuracy of the performed exercises (by analysing the data captured using KiReS). We made a full deployment of KiReS, defining step by step all the elements of a therapy: postures, movements, exercises and the therapy itself. Seven patients participated in this trial in a total of 19 sessions, and the system recorded 3865 exercise executions. The group showed general support for telerehabilitation and the possibilities that systems such as KiReS bring to physiotherapy treatment.

Emergence of virtual reality as a tool for upper limb rehabilitation: incorporation of motor control and motor learning principles

The primary focus of rehabilitation for individuals with loss of upper limb movement as a result of acquired brain injury is the relearning of specific motor skills and daily tasks. This relearning is essential because the loss of upper limb movement often results in a reduced quality of life. Although rehabilitation strives to take advantage of neuroplastic processes during recovery, results of traditional approaches to upper limb rehabilitation have not entirely met this goal. In contrast, enriched training tasks, simulated with a wide range of low- to high-end virtual reality-based simulations, can be used to provide meaningful, repetitive practice together with salient feedback, thereby maximizing neuroplastic processes via motor learning and motor recovery. Such enriched virtual environments have the potential to optimize motor learning by manipulating practice conditions that explicitly engage motivational, cognitive, motor control, and sensory feedback-based learning mechanisms. The objectives of this article are to review motor control and motor learning principles, to discuss how they can be exploited by virtual reality training environments, and to provide evidence concerning current applications for upper limb motor recovery. The limitations of the current technologies with respect to their effectiveness and transfer of learning to daily life tasks also are discussed.

Factors influencing therapists' adoption of virtual reality for brain injury rehabilitation

Virtual reality (VR) is an important emerging technology that is increasingly being introduced in health centers as a rehabilitation intervention. Quantitative research is needed to identify the factors influencing therapists' adoption of VR for brain injury rehabilitation, including barriers and facilitators to VR use, in order to inform successful implementation strategies. A measure based on the decomposed theory of planned behavior (DTPB) was developed and administered to 42 therapists; early psychometric properties are reported. Mean or median composite scores and correlations were calculated for each DTPB construct. Overall, therapists had positive attitudes toward VR, perceived it as being useful, and had positive intentions to use it more in the future. The self-efficacy composite yielded the lowest scores. The most significant barrier to adoption was time, while social influences and knowledge were the primary facilitators. Future research will explore the impact of knowledge translation interventions on these mediators of VR adoption.

Eliciting Upper Extremity Purposeful Movements Using Video Games

Background. Video games have become popular in stroke rehabilitation; however, the nature of this intervention is not fully understood. Objectives. To compare the number of ( a) purposeful and nonpurposeful repetitions of the weaker upper extremity (UE) and ( b) movement accelerations as assessed by accelerometer activity counts of the weaker and stronger UEs of individuals with chronic stroke while playing video games or participating in traditional therapy. Methods. Twenty-nine individuals (mean age 59 years, 1-7 years poststroke) took part in a group intervention of video -games (n = 15) or traditional therapy (n = 14) as part of a randomized controlled trial. During 1 - 2 sessions, participants were video-taped while wearing wrist accelerometers. Assessors counted the number of repetitions and classified movements as purposeful or nonpurposeful using videotapes. The weaker UE motor impairments were correlated to movement accelerations, to determine if participants were using their potential during the sessions. Results. Participants in the video game group performed a median of 271 purposeful movements and 37 970 activity counts compared to 48 purposeful movements and 14 872 activity counts in the traditional group ( z = −3.0, P = .001 and z = −1.9, P = .05, respectively). Participants in the traditional group performed a median of 26 nonpurposeful (exercises) compared with 0 in the video game group ( z = −4.2, P = .000). Strong significant correlations were found between the motor ability of the weak UE to repetitions of participants in both groups ( r = .86, P < .01). Participants with higher motor ability performed more repetitions. Conclusions. Video games elicited more UE purposeful repetitions and higher acceleration of movement compared with traditional therapy in individuals with chronic stroke.

Comparing Performance within a Virtual Supermarket of Children with Traumatic Brain Injury to Typically Developing Children: A Pilot Study

The purpose of this study was to determine the usability of a virtual reality environment for pediatric traumatic brain injury (TBI) by assessing the performance of a simple virtual shopping task and comparing their results to typically developing peers. Twenty children with TBI and 20 typically developing children, matched in age and sex, “shopped” for four items in a virtual supermarket (VMall). A short feedback questionnaire, Borg's scale of perceived exertion, and the Zoo Map subtest from the Behavioral Assessment of the Dysexecutive Syndrome for Children were also administered. All of the children were able to complete a four-item test within the VMall. Overall, good usability was obtained. A significant difference in shopping performance was found between the two groups; the mean shopping time and number of mistakes was higher for the children with TBI. The use of a short shopping test within a functional virtual environment enabled detection of poorer performance of children with TBI that may be due to executive function deficits. Because the task was enjoyable and motivating, the VMall may also be used to enhance participation in instrumental activities of daily living and play for children with TBI.

The GestureTek virtual reality system in rehabilitation: a scoping review

PURPOSE

To identify, to map out and to appraise research examining GestureTek virtual reality (VR) use for physical and cognitive rehabilitation and to highlight areas for future research.

METHOD

Scoping review methodology was used to systematically and comprehensively search the academic and grey literature for GestureTek-specific research. Consensus was achieved following two reviewers' independent inclusion screening, data extraction and appraisal.

RESULTS

Forty-four studies evaluated the utility and efficacy of the IREX, GX, VMall and Meal Maker software for rehabilitation across a range of populations, with few adverse events reported. Stroke and cerebral palsy research dominated, while geriatrics was largely overlooked. Efficacy research provided support for balance, mobility, upper extremity, cognitive, fitness and daily living skills outcomes for specific populations with effect sizes ranging from 0.19 to 3.34. Nevertheless, few strong quality or high-level studies are available, and no clear guidelines on optimal treatment characteristics exist. Outcomes of primary interest were at ICF body function and activity levels; evaluation of transfer of training across ICF levels is needed.

CONCLUSIONS

This literature provides preliminary evidence for the technology's efficacy for rehabilitation. Identified research gaps relate to study quality and design, treatment characteristics, populations and outcomes of interest, including transfer across ICF levels.

IMPLICATIONS FOR REHABILITATION

There is limited high-level evidence to support the use of the GestureTek virtual reality system for rehabilitation. Moderate to strong quality evidence exists primarily for the stroke and cerebral palsy populations, and primarily for balance, mobility and upper extremity outcomes. A lack of consistent outcome measures in this body of literature has created "silos" of research that cannot be quantitatively combined using a meta-analytic strategy.

Virtual Reality for Sensorimotor Rehabilitation Post-Stroke: The Promise and Current State of the Field

Developments over the past 2 years in virtual reality (VR) augmented sensorimotor rehabilitation of upper limb use and gait post-stroke were reviewed. Studies were included if they evaluated comparative efficacy between VR and standard of care, and or differences in VR delivery methods; and were CEBM (center for evidence based medicine) level 2 or higher. Eight upper limb and two gait studies were included and described using the following categories hardware (input and output), software (virtual task and feedback and presentation) intervention (progression and dose), and outcomes. Trends in the field were commented on, gaps in knowledge identified, and areas of future research and translation of VR to practice were suggested.

Effectiveness of executive functions training within a virtual supermarket for adults with traumatic brain injury: a pilot study

Impairments of executive functions (EF) significantly affect the ability to lead an independent lifestyle. Virtual environments offer a way to rehabilitate EF due to their ecological validity. The purpose of this pilot study was to examine the effectiveness of a virtual reality (VR) supermarket (VMall) for treatment of EF in patients with Traumatic Brain Injury (TBI), compared to conventional occupational therapy (OT), in order to provide initial data regarding the effect sizes for calculation of sample size as well as to establish an intervention protocol for future Randomized Control Trials (RCTs). Twelve men and women, aged 19-55 years, who had TBI resulting in EF impairments participated in this study. Outcome measures were the Multiple Errands Test-Simplified Version (MET-SV) and the Executive Function Performance Test (EFPT). Cognitive treatment provided to both groups was based on the same principles; the participants in the experimental group received 10 45-min VR-based treatment sessions and the control group participants received 10 sessions of occupational therapy cognitive retraining without VR. Baseline performance prior to intervention showed no statistically significant differences between groups. Most participants improved their performance after therapy. Following a Bonferroni correction for multiple comparisons, no significant between or within group differences were found, Nevertheless, large effect sizes (0.51) for the percent (%) relative change of the MET-SV total score and EFPT total score after intervention were high in favor of the experimental group indicating a larger improvement in EF. Based on this pilot study, results show a trend towards an advantage to VR therapy compared to cognitive retraining OT without VR, as it leads to greater improvement in complex everyday activities.

Virtual reality versus conventional treatment of reaching ability in chronic stroke: clinical feasibility study

INTRODUCTION

The objective of this study was to evaluate the potential of exercises performed in a 2D video-capture virtual reality (VR) training environment to improve upper limb motor ability in stroke patients compared to those performed in conventional therapy.

METHODS

A small sample randomized control trial, in an outpatient rehabilitation center with 12 patients with chronic stroke, aged 33-80 years, who were randomly allocated to video-capture VR therapy and conventional therapy groups. All patients participated in four clinical evaluation sessions (pre-test 1, pre-test 2, post-test, follow-up) and nine 45-minute intervention sessions over a 3-week period. Main outcomes assessed were Body Structure and Function (impairment: Fugl-Meyer Assessment [FMA]; Composite Spasticity Index [CSI]; Reaching Performance Scale for Stroke), Activity (Box and Blocks; Wolf Motor Function Test [WMFT]), and Participation (Motor Activity Log) levels of the International Classification of Functioning.

RESULTS

Improvements occurred in both groups, but more patients in the VR group improved upper limb clinical impairment (FMA, CSI) and activity scores (WMFT) and improvements occurred earlier. Patients in the VR group also reported satisfaction with the novel treatment.

CONCLUSIONS

The modest advantage of VR over conventional training supports further investigation of the effect of video-capture VR or VR combined with conventional therapy in larger-scale randomized, more intense controlled studies.

Kinematics of reaching movements in a 2-D virtual environment in adults with and without stroke

Virtual reality environments are increasingly being used for upper limb rehabilitation in poststroke patients. Our goal was to determine if arm reaching movements made in a 2-D video-capture virtual reality environment are similar to those made in a comparable physical environment. We compared arm and trunk kinematics for reaches made with the right, dominant arm to three targets (14 trials per target) in both environments by 16 adults with right poststroke hemiparesis and by eight healthy age-matched controls. Movement kinematics were recorded with a three-camera optoelectronic system at 100 samples/s. Reaching movements made by both control and stroke subjects were affected by viewing the targets in the video-capture 2-D virtual environment. Movements were slower, shorter, less straight, less accurate and involved smaller ranges of shoulder and elbow joint excursions for target reaches in the virtual environment compared to the physical environment in all subjects. Thus, there was a decrease in the overall movement quality for movements made in the 2-D virtual environment. This suggests that 2-D video-capture virtual reality environments should be used with caution when the goal of the rehabilitation program is to improve the quality of movement patterns of the upper limb.

Using virtual reality driving simulators in persons with spinal cord injury: three screen display versus head mounted display

PURPOSE

Virtual reality (VR) is a relatively new technology that is currently utilized in a wide variety of settings to test and train individuals in specialized skills. This study examines methods for improving driver retraining protocols for persons with spinal cord injury (SCI).

METHOD

We compared a VR driving simulator, under two different display conditions, a head mounted display (HMD) and a three screen display (TSD) to identify the best method for retraining driving skills following SCI.

RESULTS

Although there was minimal evidence for driving performance difficulties in the HMD condition relative to the TSD condition (e.g. greater number of times for being off course and longer stopping latencies for the HMD condition), rates of simulator sickness did not differ between display conditions.

CONCLUSIONS

Taken together, findings suggest that both the HMD and the TSD are reasonable simulator options for driver retraining in SCI.

The effectiveness of virtual reality interventions in improving balance in adults with impaired balance compared to standard or no treatment: A systematic review

BACKGROUND

Balance impairment can result in falls and reduced activities of daily living and function. Virtual reality and interactive gaming systems provide a novel and potentially environmentally flexible treatment option to improve postural stability and reduce falls in balance impaired populations. There are no existing systematic reviews in this topic area.

OBJECTIVES

To search, critically appraise and synthesise the best available evidence on whether virtual reality interventions, including interactive gaming systems, are effective at improving balance in adults with impaired balance.

INCLUSION CRITERIA

Adults with impaired, altered or reduced balance identified either through reduced balance outcome measure score or increased risk or incidence of falls.Types of interventions:Any virtual reality or interactive gaming systems used within a rehabilitative setting.The primary outcome was an objective measure of balance (i.e. balance outcome measure such as Berg Balance Score) or number and/or incidence of falls. Secondary outcome measures of interest included any adverse effects experienced, an outcome measure indicating functional balance (i.e. walking speed), quality of life (through use of an objective measure i.e. EuroQOL), and number of days in hospital due to falls.Types of studies:Randomised controlled trials (RCT).

SEARCH STRATEGY

A three-stage strategy searched the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, PsycBITE, OTseeker, Ei Compendex, Inspec, Current Controlled Trials, and the National Institute of Health Clinical Trials Database.

METHODOLOGICAL QUALITY

The methodological quality of each included study was independently assessed using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) to systematically comment on influence of bias.

DATA COLLECTION

Data was individually extracted from the included studies using the standardised JBI data extraction tool from JBI-MAStARI.

DATA SYNTHESIS

Data was analysed using Review Manager 5 software. Results were expressed as mean difference (MD) with 95% confidence intervals for continuous outcomes. Meta-analysis was not possible due to the variation of the interventions given and small number of included trials; hence, a description of the results was given.

RESULTS

Four studies were included in the systematic review. All the included studies used different types of virtual reality or interactive gaming interventions. Two of the included studies used the same balance outcome measure. There was a notable inconsistency of balance outcome measurement between all the included studies. No data was given regarding falls in any of the studies. A secondary outcome, the 10m walk test, was recorded in two of the studies.

CONCLUSIONS

The four included studies had small sample sizes and poor methodological quality. Despite the presentation of statistically significant results, the clinical significance is questionable.

IMPLICATIONS FOR PRACTICE

The review can not recommend the inclusion of virtual reality or interactive gaming systems into the rehabilitation of balance impairment based on the results of the four included studies.

IMPLICATIONS FOR RESEARCH

Further investigation in this topic area is required.