Influence of virtual reality soccer game on walking performance in robotic assisted gait training for children

Exploring new horizons: Emerging therapeutic strategies for pediatric stroke

Pediatric stroke presents unique challenges, and optimizing treatment strategies is essential for improving outcomes in this vulnerable population. This review aims to provide an overview of new, innovative, and potential treatments for pediatric stroke, with a primary objective to stimulate further research in this field. Our review highlights several promising approaches in the realm of pediatric stroke management, including but not limited to stem cell therapy and robotic rehabilitation. These innovative interventions offer new avenues for enhancing functional recovery, reducing long-term disability, and tailoring treatments to individual patient needs. The findings of this review underscore the importance of ongoing research and development of innovative treatments in pediatric stroke. These advancements hold significant clinical relevance, offering the potential to improve the lives of children affected by stroke by enhancing the precision, efficacy, and accessibility of therapeutic interventions. Embracing these innovations is essential in our pursuit of better outcomes and a brighter future for pediatric stroke care.

Gamification and neurological motor rehabilitation in children and adolescents: a systematic review

INTRODUCTION

Gamification consists of the use of games in non-playful contexts. It is widely employed in the motor rehabilitation of neurological diseases, but mainly in adult patients. The objective of this review was to describe the use of gamification in the rehabilitation of children and adolescents with neuromotor impairment.

METHODS

We performed a systematic review of clinical trials published to date on the MEDLINE (PubMed), Scielo, SCOPUS, Dialnet, CINAHL, and PEDro databases, following the PRISMA protocol. The methodological quality of the studies identified was assessed using the PEDro scale.

RESULTS

From a total of 469 studies, 11 clinical trials met the inclusion criteria. We analysed the gamification systems used as part of the rehabilitation treatment of different neuromotor conditions in children and adolescents. Cerebral palsy was the most frequently studied condition (6 studies), followed by developmental coordination disorder (3), neurological gait disorders (1), and neurological impairment of balance and coordination (1).

CONCLUSION

The use of gamification in rehabilitation is helpful in the conventional treatment of neuromotor disorders in children and adolescents, with increased motivation and therapeutic adherence being the benefits with the greatest consensus among authors. While strength, balance, functional status, and coordination also appear to improve, future research should aim to determine an optimal dosage.

Application of Virtual Reality-Assisted Exergaming on the Rehabilitation of Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

BACKGROUND

Rehabilitation programs for children with cerebral palsy (CP) aim to improve their motor and cognitive skills through repeated and progressively challenging exercises. However, these exercises can be tedious and demotivating, which can affect the effectiveness and feasibility of the programs. To overcome this problem, virtual reality VR-assisted exergaming has emerged as a novel modality of physiotherapy that combines fun and motivation with physical activity. VR exergaming allows children with CP to perform complex movements in a secure and immersive environment, where they can interact with virtual objects and scenarios. This enhances their active engagement and learning, as well as their self-confidence and enjoyment. We aim to provide a comprehensive overview of the current state of research on VR exergaming for CP rehabilitation. The specific objectives are: To identify and describe the existing studies that have investigated the effects of VR exergaming on motor function and participation outcomes in children with CP. In addition, we aim to identify and discuss the main gaps, challenges, and limitations in the current research on VR exergaming for CP rehabilitation. Finally, we aim to provide recommendations and suggestions for future research and practice in this field.

METHODS

In June 2023, we conducted a systematic search on Scopus, Web of Science, PubMed, Cochrane, and Embase for randomized trials and cohort studies that applied VR-assisted exergaming to rehabilitating patients with CP. The inclusion criteria encompassed the following: (1) Randomized controlled trials (RCTs) and cohort studies involving the rehabilitation of children with CP; (2) the application of VR-based exergaming on the rehabilitation; (3) in comparison with conventional rehabilitation/usual care. The quality of the selected RCTs was evaluated using Cochrane's tool for risk of bias assessment bias includes. Whereas the quality of cohort studies was assessed using the National Institutes of Health (NIH) tool.

RESULTS

The systematic search of databases retrieved a total of 2576 studies. After removing 863 duplicates, 1713 studies underwent title and abstract screening, and 68 studies were then selected as eligible for full-text screening. Finally, 45 studies were involved in this review (n = 1580), and 24 of those were included in the quantitative analysis. The majority of the included RCTs had a low risk of bias regarding study reporting, participants' attrition, and generating a random sequence. Nearly half of the RCTs ensured good blinding of outcomes assessors. However, almost all the RCTs were unclear regarding the blinding of the participants and the study personnel. The 2020 retrospective cohort study conducted at Samsung Changwon Hospital, investigating the effects of virtual reality-based rehabilitation on upper extremity function in children with cerebral palsy, demonstrated fair quality in its methodology and findings. VR-assisted exergaming was more effective than conventional physiotherapy in improving the Gross Motor Function Measurement (GMFM)-88 score (MD = 0.81; 95% CI [0.15, 1.47], p-value = 0.02) and the GMFM walking and standing dimensions (MD = 1.45; 95% CI [0.48, 2.24], p-value = 0.003 and MD = 3.15; 95% CI [0.87, 5.42], p-value = 0.007), respectively. The mobility and cognitive domains of the Pediatric Evaluation of Disability Inventory score (MD = 1.32; 95% CI [1.11, 1.52], p-value < 0.001) and (MD = 0.81; 95% CI [0.50, 1.13], p-value < 0.0001) were also improved. The Canadian Occupational Performance Measure performance domain (MD = 1.30; 95% CI [1.04, 1.56], p-value < 0.001), the WeeFunctional Independence Measure total score (MD = 6.67; 95% CI [6.36, 6.99], p-value < 0.0001), and the Melbourne Assessment of Unilateral Upper Limb Function-2 score (p-value < 0.001) improved as well. This new intervention is similarly beneficial as conventional therapy in improving other efficacy measures.

CONCLUSIONS

Our findings suggest that VR-assisted exergaming may have some advantages over conventional rehabilitation in improving CP children's functioning and performance in daily life activities, upper and lower limb mobility, and cognition. VR-assisted exergaming seems to be as effective as conventional physiotherapy in the other studied function measures. With its potential efficacy, better feasibility, no reported side effects, and entertaining experience, VR-assisted exergaming may be a viable complementary approach to conventional physiotherapy in rehabilitating children with CP.

Patient Experience in Adjunct Controller-Free Hand Tracking Virtual Reality Tasks for Upper-Limb Occupational Therapy Rehabilitation

Benefits of immersive virtual reality rehabilitation (VRR) include increased motivation and improved transfer of skills to real-world tasks. The introduction of Oculus hand-tracking technology allowed for the development of VRR games that do not need virtual reality (VR) hand controllers. This is beneficial as participants with upper limb impairments/injuries may have difficulties with/be limited in using/manipulating VR hand controllers. In this project, a VRR game was developed and evaluated. The aim of this study was to determine patient experience when using VRR as an adjunct to upper-limb rehabilitation. N  =  20 participants receiving upper limb rehabilitation completed a series of VRR tasks by playing the "smoothie bar" VRR game. After the completion of the VRR tasks, the participant experience was evaluated via a study-specific questionnaire. Key findings include 95% agreement that VRR tasks were fun and engaging and 75% agreed that VR tasks will be helpful to include in their rehabilitation. Hands-tracking VRR has a high potential to be used as an adjunct intervention in upper limb rehabilitation.

1D-Convolutional Neural Networks can Quantify Therapy Content of Children and Adolescents Walking in a Robot-Assisted Gait Trainer

Therapy content, consisting of device parameter settings and therapy instructions, is crucial for an effective robot-assisted gait therapy program. Settings and instructions depend on the therapy goals of the individual patient. While device parameters can be recorded by the robot, therapeutic instructions and associated patient responses are currently difficult to capture. This limits the transferability of successful therapeutic approaches between clinics. Here, we propose that 1D-convolutional neural networks can be used to relate patient behavior during individual steps to the instructions given as a surrogate for the patient's intent. Our model takes the surface electromyography patterns of two leg muscles as input and predicts the given instruction as output. We tested this approach with data from 20 healthy children walking in a robot-assisted gait trainer with 5 different instructions. Our model performs well, with a classification accuracy of almost 90%, when the instruction targets specific aspects of gait, such as step length. This shows that 1D-convolutional neural networks are a viable tool for quantifying therapy content. Thus, they could help compare therapy approaches and identify effective strategies.

Technology Assisted Rehabilitation Patient Perception Questionnaire (TARPP-Q): development and implementation of an instrument to evaluate patients' perception during training

BACKGROUND

The introduction of technology-assisted rehabilitation (TAR) uncovers promising challenges for the treatment of motor disorders, particularly if combined with exergaming. Patients with neurological diseases have proved to benefit from TAR, improving their performance in several activities. However, the subjective perception of the device has never been fully addressed, being a conditioning factor for its use. The aims of the study were: (a) to develop a questionnaire on patients' personal experience with TAR and exergames in a real-world clinical setting; (b) to administer the questionnaire to a pilot group of neurologic patients to assess its feasibility and statistical properties.

METHODS

A self-administrable and close-ended questionnaire, Technology Assisted Rehabilitation Patient Perception Questionnaire (TARPP-Q), designed by a multidisciplinary team, was developed in Italian through a Delphi procedure. An English translation has been developed with consensus, for understandability purposes. The ultimate version of the questionnaire was constituted of 10 questions (5 with multiple answers), totalling 29 items, exploring the patient's performance and personal experience with TAR with Augmented Performance Feedback. TARPP-Q was then administered pre-post training in an observational, feasible, multi-centric study. The study involved in-patients aged between 18 and 85 with neurological diseases, admitted for rehabilitation with TAR (upper limb or gait). FIM scale was run to control functional performance.

RESULTS

Forty-four patients were included in the study. All patients answered the TARPP-Q autonomously. There were no unaccounted answers. Exploratory factor analyses identified 4 factors: Positive attitude, Usability, Hindrance perception, and Distress. Internal consistency was measured at T0. The values of Cronbach's alpha ranged from 0.72 (Distress) to 0.92 (Positive attitude). Functional Independence Measure (FIM®) scores and all TARPP-Q factors (Positive attitude, Usability, Hindrance perception, except for Distress (p = 0.11), significantly improved at the end of the treatment. A significant positive correlation between Positive attitude and Usability was also recorded.

CONCLUSIONS

The TARPP-Q highlights the importance of patients' personal experience with TAR and exergaming. Large-scale applications of this questionnaire may clarify the role of patients' perception of training effectiveness, helping to customize devices and interventions.

Efficacy of Robot-Assisted Gait Therapy Compared to Conventional Therapy or Treadmill Training in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Motor, gait and balance disorders reduce functional capabilities for activities of daily living in children with cerebral palsy (CP). Robot-assisted gait therapy (RAGT) is being used to complement conventional therapy (CT) or treadmill therapy (TT) in CP rehabilitation. The aim of this systematic review is to assess the effect of RAGT on gait, balance and functional independence in CP children, in comparison to CT or TT.

METHODS

We have conducted a systematic review with meta-analysis. A search in PubMed Medline, Web of Science, Scopus, CINAHL, PEDro and SciELO has been conducted for articles published until October 2022. Controlled clinical trials (CCT), in which RAGT was compared to TT or CT and assessed gait speed, step and stride length, width step, walking distance, cadence, standing ability, walking, running and jumping ability, gross motor function and functional independence in children with CP, have been included. Methodological quality was assessed with the PEDro scale and the pooled effect was calculated with Cohen's Standardized Mean Difference (SMD) and its 95% Confidence Interval (95% CI).

RESULTS

A total of 15 CCTs have been included, providing data from 413 participants, with an averaged methodological quality of 5.73 ± 1.1 points in PEDro. The main findings of this review are that RAGT shows better results than CT in the post-intervention assessment for gait speed (SMD 0.56; 95% CI 0.03 to 1.1), walking distance (SMD 2; 95% CI 0.36 to 3.65) and walking, running and jumping ability (SMD 0.63; 95% CI 0.12 to 1.14).

CONCLUSIONS

This study shows that the effect of RAGT is superior to CT on gait speed, walking distance and walking, running and jumping ability in post-intervention, although no differences were found between RAGT and TT or CT for the remaining variables.

Clinical feasibility and preliminary outcomes of a novel mixed reality system to manage phantom pain: a pilot study

Background

To assess the clinical feasibility of a virtual mirror therapy system in a pilot sample of patients with phantom pain.

Methods

Our Mixed reality system for Managing Phantom Pain (Mr. MAPP) mirrors the preserved limb to visualize the amputated limb virtually and perform exercises. Seven patients with limb loss and phantom pain agreed to participate and received the system for 1-month home use. Outcome measures were collected at baseline and 1 month.

Results

Four (of seven recruited) participants completed the study, which was temporarily suspended due to COVID-19 restrictions. At 1 month, in-game data showed a positive trend, but pain scores showed no clear trends. Functioning scores improved for 1 participant.

Conclusions

Mr. MAPP is feasible and has the potential to improve pain and function in patients with phantom pain.

Trial registration

Clinical Trials Registration, NCT04529083

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01187-w.

Virtual reality combined with robot-assisted gait training to improve walking ability of children with cerebral palsy: A randomized controlled trial

BACKGROUND

Children with cerebral palsy (CP) have disorders of posture and movement and which can limit physical activities such as walkingOBJECTIVE: This study aims to investigate the effectiveness of virtual reality (VR) combined with robot-assisted gait training (RAGT) on walking ability in children with CP and clarify the most effective degree of weight reduction.

METHODS

Sixty CP children were recruited and randomly allocated into four different groups. The control group received conventional physical therapy (n= 15), and task groups performed VR combined with RAGT with 15% (Group A, n= 15) /30% (Group B, n= 15) /45% (Group C, n= 15) weight loss. All participants were given 50 min of therapy per session four times a week for 12 weeks and were assessed pre-and post-test with the surface electromyography (EMG), the Modified Ashworth Scale, the Gross Motor Function Measure (GMFM) dimension E and D, and Six-Minute Walking Test (6-MWT).

RESULTS

All indicators had improved significantly in each group after the intervention (P< 0.05). The result of our study demonstrated that the more effective impacts of VR combined with RAGT on walking ability compared to the control group (P< 0.05), and 30% of weight loss had the best improvement in CP children (P< 0.01).

CONCLUSIONS

VR combined RAGT can effectively improve walking ability in children with CP, especially when the weight loss is 30%.

Gaming Technology for Pediatric Neurorehabilitation: A Systematic Review

INTRODUCTION

The emergence of gaming technologies, such as videogames and virtual reality, provides a wide variety of possibilities in intensively and enjoyably performing rehabilitation for children with neurological disorders. Solid evidence-based results are however required to promote the use of different gaming technologies in pediatric neurorehabilitation, while simultaneously exploring new related directions concerning neuro-monitoring and rehabilitation in familiar settings.

AIM OF THE STUDY AND METHODS

In order to analyze the state of the art regarding the available gaming technologies for pediatric neurorehabilitation, Scopus and Pubmed Databases have been searched by following: PRISMA statements, PICOs classification, and PEDro scoring.

RESULTS

43 studies have been collected and classified as follows: 11 feasibility studies; six studies proposing home-system solutions; nine studies presenting gamified robotic devices; nine longitudinal intervention trials; and eight reviews. Most of them rely on feasibility or pilot trials characterized by small sample sizes and short durations; different methodologies, outcome assessments and terminologies are involved; the explored spectrum of neurological conditions turns out to be scanty, mainly including the most common and wider debilitating groups of conditions in pediatric neurology: cerebral palsy, brain injuries and autism.

CONCLUSION

Even though it highlights reduced possibilities of drawing evidence-based conclusions due to the above outlined biases, this systematic review raises awareness among pediatricians and other health professionals about gaming technologies. Such a review also points out a definite need of rigorous studies that clearly refer to the underlying neuroscientific principles.

Gait changes following robot-assisted gait training in children with cerebral palsy

This study investigated changes of gait pattern induced by a 4-week robot-assisted gait training (RAGT) in twelve ambulatory spastic diparesis children with cerebral palsy (CP) aged 10.4+/-3.2 years old by using computerized gait analysis (CGA). Pre-post intervention CGA data of children with CP was contrasted to the normative data of typically developing children by using cross-correlation and statistically evaluated by a Wilcoxon test. Significant pre-post intervention changes (p<0.01) include: decreased muscle activity of biceps femoris, rectus femoris, and tibialis anterior; a decrease in range of internal hip joint rotation, higher cadence, step length, and increased stride time. This study suggests that RAGT can be used in muscle reeducation and improved hip joint motion range in ambulatory children with CP.

A Novel Clinical-Driven Design for Robotic Hand Rehabilitation: Combining Sensory Training, Effortless Setup, and Large Range of Motion in a Palmar Device

Neurorehabilitation research suggests that not only high training intensity, but also somatosensory information plays a fundamental role in the recovery of stroke patients. Yet, there is currently a lack of easy-to-use robotic solutions for sensorimotor hand rehabilitation. We addressed this shortcoming by developing a novel clinical-driven robotic hand rehabilitation device, which is capable of fine haptic rendering, and that supports physiological full flexion/extension of the fingers while offering an effortless setup. Our palmar design, based on a parallelogram coupled to a principal revolute joint, introduces the following novelties: (1) While allowing for an effortless installation of the user's hand, it offers large range of motion of the fingers (full extension to 180° flexion). (2) The kinematic design ensures that all fingers are supported through the full range of motion and that the little finger does not lose contact with the finger support in extension. (3) We took into consideration that a handle is usually comfortably grasped such that its longitudinal axis runs obliquely from the metacarpophalangeal joint of the index finger to the base of the hypothenar eminence. (4) The fingertip path was optimized to guarantee physiologically correct finger movements for a large variety of hand sizes. Moreover, the device possesses a high mechanical transparency, which was achieved using a backdrivable cable transmission. The transparency was further improved with the implementation of friction and gravity compensation. In a test with six healthy participants, the root mean square of the human-robot interaction force was found to remain as low as 1.37 N in a dynamic task. With its clinical-driven design and easy-to-use setup, our robotic device for hand sensorimotor rehabilitation has the potential for high clinical acceptance, applicability and effectiveness.

Temporal Fluctuation of Mood in Gaming Task Modulates Feedback Negativity: EEG Study With Virtual Reality

Feedback outcomes are generally classified into positive and negative feedback. People often predict a feedback outcome with information that is based on both objective facts and uncertain subjective information, such as a mood. For example, if an action leads to good results consecutively, people performing the action overestimate the behavioral result of the next action. In electroencephalogram measurements, negative feedback evokes negative potential, called feedback negativity, and positive feedback evokes positive potential, called reward positivity. The present study investigated the relationship between the degree of the mood caused by the feedback outcome and the error-related brain potentials. We measured the electroencephalogram activity while the participants played a virtual reality shooting game. The experimental task was to shoot down a cannonball flying toward the player using a handgun. The task difficulty was determined from the size and curve of the flying cannonball. These gaming parameters affected the outcome probability of shooting the target in the game. We also implemented configurations in the game, such as the player’s life points and play times. These configurations affected the outcome magnitude of shooting the target in the game. Moreover, we used the temporal accuracy of shooting in the game as the parameter of the mood. We investigated the relationship between these experimental features and the event-related potentials using the single-trial-based linear mixed-effects model analysis. The feedback negativity was observed at an error trial, and its amplitude was modulated with the outcome probability and the mood. Conversely, reward positivity was observed at hit trials, but its amplitude was modulated with the outcome probability and outcome magnitude. This result suggests that feedback negativity is enhanced according to not only the feedback probability but also the mood that was changed depending on the temporal gaming outcome.

Gamification and neurological motor rehabilitation in children and adolescents: A systematic review

INTRODUCTION

Gamification consists of the use of games in non-playful contexts. It is widely employed in the motor rehabilitation of neurological diseases, but mainly in adult patients. The objective of this review was to describe the use of gamification in the rehabilitation of children and adolescents with neuromotor impairment.

METHODS

We performed a systematic review of clinical trials published to date on the MEDLINE (PubMed), Scielo, SCOPUS, Dialnet, CINAHL, and PEDro databases, following the PRISMA protocol. The methodological quality of the studies identified was assessed using the PEDro scale.

RESULTS

From a total of 469 studies, 10 clinical trials met the inclusion criteria. We analysed the gamification systems used as part of the rehabilitation treatment of different neuromotor conditions in children and adolescents. Cerebral palsy was the most frequently studied condition (6studies), followed by developmental coordination disorder (3), and neurological impairment of balance and coordination (1).

CONCLUSION

The use of gamification in rehabilitation is helpful in the conventional treatment of neuromotor disorders in children and adolescents, with increased motivation and therapeutic adherence being the benefits with the greatest consensus among authors. While strength, balance, functional status, and coordination also appear to improve, future research should aim to determine an optimal dosage.

Virtual reality versus Biodex training in adolescents with chronic ankle instability: a randomized controlled trial

INTRODUCTION

Ankle instability is a common injury in athletes, affecting the quality of life, functional limitation, as well as static and dynamic balance. The aim of the study was to compare the efficacy of virtual reality and Biodex balance training in the treatment of ankle instability in adolescent athletes.

MATERIAL AND METHODS

Ninety football players were enrolled in this study after the assessment of their eligibility. Their age ranged from 12 to 16 years. They were randomly allocated to three groups of equal numbers. Group 1 received a guideline protocol, group 2 received the same guideline protocol in addition to Wii Sport Training, and group 3 received the same guideline protocol in addition to Biodex balance training. All groups received treatment protocols three times a week for 3 months. Outcome measures included the stability indices (overall stability, anteroposterior stability, and mediolateral) measured by the Biodex Balance System as well as ankle instability measured by the Cumberland Ankle Instability Tool. Measurements were collected at the baseline and after 3 months of treatment.

RESULTS

Post-treatment findings revealed a statistically significant decrease in the overall, anteroposterior, and mediolateral stability indices, as well as significant increase in Cumberland Ankle Instability outcomes of all groups (p < 0.05). On the other hand, there were no statistically significant differences between the virtual reality and Biodex balance training groups.

CONCLUSIONS

Virtual reality training has a significant effect which appears to be similar to the Biodex balance training in adolescent athletes with chronic ankle instability.

How Commercially Available Virtual Reality-Based Interventions Are Delivered and Reported in Gait, Posture, and Balance Rehabilitation: A Systematic Review

OBJECTIVE

Virtual reality (VR) technologies are increasingly used in physical rehabilitation; however, it is unclear how VR interventions are being delivered, and, in particular, the role of the therapist remains unknown. The purpose of this study was to systematically evaluate how commercially available VR technologies are being implemented in gait, posture, and balance rehabilitation, including justification, content, procedures, and dosage of the intervention and details of the therapist role.

METHODS

Five databases were searched between 2008 and 2018. Supervised interventional trials with >10 adult participants using commercially available VR technologies to address mobility limitations were independently selected by 2 authors. One author extracted reported intervention characteristics into a predesigned table and assessed methodological quality, which was independently verified by a second author. A total of 29 studies were included.

RESULTS

Generally, minimal clinical reasoning was provided to justify technology or activity selection, with recreational systems and games used most commonly (n = 25). All but 1 study used a single interventional technology. When explicitly described, the intervention was delivered by a physical therapist (n = 14), a therapist assistant (n = 2), both (n = 1), or an occupational therapist (n = 1). Most studies reported supervision (n = 12) and safeguarding (n = 8) as key therapist roles, with detail of therapist feedback less frequently reported (n = 4). Therapist involvement in program selection, tailoring, and progression was poorly described.

CONCLUSION

Intervention protocols of VR rehabilitation studies are incompletely described and generally lack detail on clinical rationale for technology and activity selection and on the therapist role in intervention design and delivery, hindering replication and translation of research into clinical practice. Future studies utilizing commercially available VR technologies should report all aspects of intervention design and delivery and consider protocols that allow therapists to exercise clinical autonomy in intervention delivery.

IMPACT STATEMENT

The findings of this systematic review have highlighted that VR rehabilitation interventions targeting gait, posture, and balance are primarily delivered by physical therapists, whose most reported role was supervision and safeguarding. There was an absence of detail regarding complex clinical skills, such as tailoring of the intervention and reasoning for the choice of technology and activity. This uncertainty around the role of the therapist as an active ingredient in VR-based rehabilitation hinders the development of implementation guidelines. To inform the optimal involvement of therapists in VR rehabilitation, it is essential that future studies report on all aspects of VR intervention design and delivery.

A Virtual Reality-Supported Intervention for Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: Mixed Methods Study

BACKGROUND

The uptake of traditional pulmonary rehabilitation classes by patients with chronic obstructive pulmonary disease (COPD) is poor because of personal factors that prevent accessibility to the venue. Therefore, there is a need for innovative methods of pulmonary rehabilitation, and virtual reality (VR) could be a promising technology for patients with COPD to access services remotely.

OBJECTIVE

This study aimed to investigate whether VR improves compliance with pulmonary rehabilitation among patients with COPD, a particularly vulnerable patient group (Medical Research Council [MRC] 4 or 5), and whether VR provides a credible alternative to traditional pulmonary rehabilitation programs.

METHODS

This was an 8-week patient trial using an innovative VR pulmonary rehabilitation program. A purposive sample of 10 patients with COPD graded MRC 4 or 5 and registered at a selected health care center and a hospital in Cumbria, United Kingdom, were included. Qualitative (focus groups and interviews) data were collected, and to further support the qualitative findings, quantitative data (self-report patient surveys) were gathered before and after the 8-week trial. The 5 self-reported surveys included the Patient Activation Measure, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Short Physical Performance Battery, and the Edmonton Frail Scale.

RESULTS

In a thematic analysis of the qualitative data, 11 themes emerged specific to delivering pulmonary rehabilitation using VR. The quantitative data further support the qualitative findings by revealing significant improvements in all physical measures.

CONCLUSIONS

Overall, this study demonstrates how remotely supervised VR-based pulmonary rehabilitation could help to overcome current issues and limitations associated with providing this service to patients with COPD at scale.

Home-Based Functional Electrical Stimulation-Assisted Hand Therapy Video Games for Children With Hemiplegia: Development and Proof-of-Concept

We describe the development and three case reports of a home-based intervention for children with hand hemiplegia that integrates custom video games with contralaterally controlled functional electrical stimulation (CCFES). With CCFES, stimulated opening of the more-affected hand is modulated by volitional opening of the less-affected hand. Video games that solicit goal-oriented, skill-requiring movement have shown promise for treating hemiplegia, but they have not previously been combined with electrical stimulation in children. Three children ages 8, 9, and 11 with moderate-to-severe hand hemiplegia were assigned six weeks of therapy in lab and at home. The goal was to determine if children could tolerate 9 lab treatment sessions and administer up to 7.5 hrs/wk of CCFES video game therapy at home. The feasibility of this intervention for home use was assessed by device logs, end-of-treatment interviews, and motor function/impairment assessments. With caregiver help, the children were all able to attend 9 lab sessions and built up to 7.5 hrs/wk of therapy by week 3. They averaged 5-7 hrs/wk of home intervention overall. Motor outcomes improved for all three participants at treatment end, but mostly regressed at 4-weeks follow-up. Individual improvements at treatment end exceeded minimum detectable or clinically important thresholds for Assisting Hands Assessment, Fugl-Meyer Assessment, and Melbourne Motor Assessment 2. We found preliminary indications that CCFES-integrated video game therapy can provide a high dose of hand motor control therapy at home and in the lab. Improvements in motor outcomes were also observed, but more development and study is needed.

Robotic Technology in Pediatric Neurorehabilitation. A Pilot Study of Human Factors in an Italian Pediatric Hospital

The introduction of robotic neurorehabilitation among the most recent technologies in pediatrics represents a new opportunity to treat pediatric patients. This study aims at evaluating the response of physiotherapists, patients and their parents to this new technology. The study considered the outcomes of technological innovation in physiotherapists (perception of the workload, satisfaction), as well as that in patients and their parents (quality of life, expectations, satisfaction) by comparing the answers to subjective questionnaires of those who made use of the new technology with those who used the traditional therapy. A total of 12 workers, 46 patients and 47 parents were enrolled in the study. Significant differences were recorded in the total workload score of physiotherapists who use the robotic technology compared with the traditional therapy (p < 0.001). Patients reported a higher quality of life and satisfaction after the use of the robotic neurorehabilitation therapy. The parents of patients undergoing the robotic therapy have moderately higher expectations and satisfaction than those undergoing the traditional therapy. In this pilot study, the robotic neurorehabilitation technique involved a significant increase in the patients' and parents' expectations. As it frequently happens in the introduction of new technologies, physiotherapists perceived a greater workload. Further studies are needed to verify the results achieved.

Augmented and Virtual Reality Evolution and Future Tendency

Augmented reality and virtual reality technologies are increasing in popularity. Augmented reality has thrived to date mainly on mobile applications, with games like Pokémon Go or the new Google Maps utility as some of its ambassadors. On the other hand, virtual reality has been popularized mainly thanks to the videogame industry and cheaper devices. However, what was initially a failure in the industrial field is resurfacing in recent years thanks to the technological improvements in devices and processing hardware. In this work, an in-depth study of the different fields in which augmented and virtual reality have been used has been carried out. This study focuses on conducting a thorough scoping review focused on these new technologies, where the evolution of each of them during the last years in the most important categories and in the countries most involved in these technologies will be analyzed. Finally, we will analyze the future trend of these technologies and the areas in which it is necessary to investigate to further integrate these technologies into society.

Haptic Error Modulation Outperforms Visual Error Amplification When Learning a Modified Gait Pattern

Robotic algorithms that augment movement errors have been proposed as promising training strategies to enhance motor learning and neurorehabilitation. However, most research effort has focused on rehabilitation of upper limbs, probably because large movement errors are especially dangerous during gait training, as they might result in stumbling and falling. Furthermore, systematic large movement errors might limit the participants' motivation during training. In this study, we investigated the effect of training with novel error modulating strategies, which guarantee a safe training environment, on motivation and learning of a modified asymmetric gait pattern. Thirty healthy young participants walked in the exoskeletal robotic system Lokomat while performing a foot target-tracking task, which required an increased hip and knee flexion in the dominant leg. Learning the asymmetric gait pattern with three different strategies was evaluated: (i) No disturbance: no robot disturbance/guidance was applied, (ii) haptic error amplification: unsafe and discouraging large errors were limited with haptic guidance, while haptic error amplification enhanced awareness of small errors relevant for learning, and (iii) visual error amplification: visually observed errors were amplified in a virtual reality environment. We also evaluated whether increasing the movement variability during training by adding randomly varying haptic disturbances on top of the other training strategies further enhances learning. We analyzed participants' motor performance and self-reported intrinsic motivation before, during and after training. We found that training with the novel haptic error amplification strategy did not hamper motor adaptation and enhanced transfer of the practiced asymmetric gait pattern to free walking. Training with visual error amplification, on the other hand, increased errors during training and hampered motor learning. Participants who trained with visual error amplification also reported a reduced perceived competence. Adding haptic disturbance increased the movement variability during training, but did not have a significant effect on motor adaptation, probably because training with haptic disturbance on top of visual and haptic error amplification decreased the participants' feelings of competence. The proposed novel haptic error modulating controller that amplifies small task-relevant errors while limiting large errors outperformed visual error augmentation and might provide a promising framework to improve robotic gait training outcomes in neurological patients.

A Survey of Assistive Technologies for Assessment and Rehabilitation of Motor Impairments in Multiple Sclerosis

Multiple sclerosis (MS) is a disease that affects the central nervous system, which consists of the brain and spinal cord. Although this condition cannot be cured, proper treatment of persons with MS (PwMS) can help control and manage the relapses of several symptoms. In this survey article, we focus on the different technologies used for the assessment and rehabilitation of motor impairments for PwMS. We discuss sensor-based and robot-based solutions for monitoring, assessment and rehabilitation. Among MS symptoms, fatigue is one of the most disabling features, since PwMS may need to put significantly more intense effort toward achieving simple everyday tasks. While fatigue is a common symptom across several neurological chronic diseases, it remains poorly understood for various reasons, including subjectivity and variability among individuals. To this end, we also investigate recent methods for fatigue detection and monitoring. The result of this survey will provide both clinicians and researchers with valuable information on assessment and rehabilitation technologies for PwMS, as well as providing insights regarding fatigue and its effect on performance in daily activities for PwMS.

Motivation in pediatric motor rehabilitation: A systematic search of the literature using the self-determination theory as a conceptual framework

OBJECTIVE

Motivation is suggested as an important factor in pediatric motor rehabilitation. Therefore, we reviewed the existing evidence of (motivational) motor rehabilitation paradigms, and how motivation influences rehabilitation outcome using self-determination theory as conceptual framework.

METHODS

PubMed and Web-of-Science databases were systematically searched until June 2015. Data were independently extracted and critiqued for quality by three authors. Studies reporting motivational aspects were included. Most studies examined new technology (e.g., virtual reality [VR]).

RESULTS

Out of 479 records, three RCT, six case-control, and six non-comparative studies were included with mixed quality. Motivation was rarely reported. Training individualization to the child's capabilities with more variety seemed promising to increase motivation. Motivation increased when the exercises seemed helpful for daily activities.

CONCLUSIONS

Motivation in pediatric rehabilitation should be comprehensively assessed within a theoretical framework as there are indications that motivated children have better rehabilitation outcomes, depending on the aspect of motivation.

Robotic Rehabilitation and Spinal Cord Injury: a Narrative Review

Mobility after spinal cord injury (SCI) is among the top goals of recovery and improvement in quality of life. Those with tetraplegia rank hand function as the most important area of recovery in their lives, and those with paraplegia, walking. Without hand function, emphasis in rehabilitation is placed on accessing one's environment through technology. However, there is still much reliance on caretakers for many activities of daily living. For those with paraplegia, if incomplete, orthoses exist to augment walking function, but they require a significant amount of baseline strength and significant energy expenditure to use. Options for those with motor complete paraplegia have traditionally been limited to the wheelchair. While wheelchairs provide a modified level of independence, wheelchair users continue to face difficulties in access and mobility. In the past decade, research in SCI rehabilitation has expanded to include external motorized or robotic devices that initiate or augment movement. These robotic devices are used with 2 goals: to enhance recovery through repetitive, functional movement and increased neural plasticity and to act as a mobility aid beyond orthoses and wheelchairs. In addition, lower extremity exoskeletons have been shown to provide benefits to the secondary medical conditions after SCI such as pain, spasticity, decreased bone density, and neurogenic bowel. In this review, we discuss advances in robot-guided rehabilitation after SCI for the upper and lower extremities, as well as potential adjuncts to robotics.

The Implementation and Validation of a Virtual Environment for Training Powered Wheelchair Manoeuvres

Navigating a powered wheelchair and avoiding collisions is often a daunting task for new wheelchair users. It takes time and practice to gain the coordination needed to become a competent driver and this can be even more of a challenge for someone with a disability. We present a cost-effective virtual reality (VR) application that takes advantage of consumer level VR hardware. The system can be easily deployed in an assessment centre or for home use, and does not depend on a specialized high-end virtual environment such as a Powerwall or CAVE. This paper reviews previous work that has used virtual environments technology for training tasks, particularly wheelchair simulation. We then describe the implementation of our own system and the first validation study carried out using thirty three able bodied volunteers. The study results indicate that at a significance level of 5 percent then there is an improvement in driving skills from the use of our VR system. We thus have the potential to develop the competency of a wheelchair user whilst avoiding the risks inherent to training in the real world. However, the occurrence of cybersickness is a particular problem in this application that will need to be addressed.

A systematic review of game technologies for pediatric patients

Children in hospital are subjected to multiple negative stimuli that may hinder their development and social interactions. Although game technologies are thought to improve children's experience in hospital, there is a lack of information on how they can be used effectively. This paper presents a systematic review of the literature on the existing approaches in this context to identify gaps for future research. A total of 1305 studies were identified, of which 75 were thoroughly analyzed according to our review protocol. The results show that the most common approach is to design mono-user games with traditional computers or monitor-based video consoles, which serve as a distractor or a motivator for physical rehabilitation for primary school children undergoing fearful procedures such as venipuncture, or those suffering chronic, neurological, or traumatic diseases/injures. We conclude that, on the one hand, game technologies seem to present physical and psychological benefits to pediatric patients, but more research is needed on this. On the other hand, future designers of games for pediatric hospitalization should consider: 1. The development for kindergarten patients and adolescents, 2. Address the psychological impact caused by long-term hospitalization, 3. Use collaboration as an effective game strategy to reduce patient isolation, 4. Have purposes other than distraction, such as socialization, coping with emotions, or fostering physical mobility, 5. Include parents/caregivers and hospital staff in the game activities; and 6. Exploit new technological artifacts such as robots and tangible interactive elements to encourage intrinsic motivation.

Effect of virtual reality versus conventional physiotherapy on upper extremity function in children with obstetric brachial plexus injury

OBJECTIVES

The objective was to evaluate the effects of virtual reality versus conventional physiotherapy on upper extremity function in children with obstetric brachial plexus injury.

METHODS

Forty children with Erb's palsy were selected for this randomized controlled study. They were assigned randomly to either group A (conventional physiotherapy program) or group B (virtual reality program using Armeo® spring for 45 min three times/week for 12 successive weeks). Mallet system scores for shoulder function and shoulder abduction, and external rotation range of motion (ROM) were obtained; shoulder abductor, and external rotators isometric strength were evaluated pre-and post-treatment using Mallet scoring system, standard universal goniometer, and handheld dynamometer.

RESULTS

The results of this study indicate that the children in both groups showed improvement in shoulder functions post-treatment with greater improvements in group B. The abduction muscle strength after treatment was 8.53 and 11.3 Nm for group A and group B, respectively. The external rotation muscle strength after treatment was 5.88 and 7.45 Nm for group A and group B, respectively.

CONCLUSIONS

The virtual reality program is a significantly more effective than conventional physiotherapy program in improving the upper extremity functions in children with obstetric brachial plexus injury.

The role of virtual reality in improving motor performance as revealed by EEG: a randomized clinical trial

BACKGROUND

Many studies have demonstrated the usefulness of repetitive task practice by using robotic-assisted gait training (RAGT) devices, including Lokomat, for the treatment of lower limb paresis. Virtual reality (VR) has proved to be a valuable tool to improve neurorehabilitation training. The aim of our pilot randomized clinical trial was to understand the neurophysiological basis of motor function recovery induced by the association between RAGT (by using Lokomat device) and VR (an animated avatar in a 2D VR) by studying electroencephalographic (EEG) oscillations.

METHODS

Twenty-four patients suffering from a first unilateral ischemic stroke in the chronic phase were randomized into two groups. One group performed 40 sessions of Lokomat with VR (RAGT + VR), whereas the other group underwent Lokomat without VR (RAGT-VR). The outcomes (clinical, kinematic, and EEG) were measured before and after the robotic intervention.

RESULTS

As compared to the RAGT-VR group, all the patients of the RAGT + VR group improved in the Rivermead Mobility Index and Tinetti Performance Oriented Mobility Assessment. Moreover, they showed stronger event-related spectral perturbations in the high-γ and β bands and larger fronto-central cortical activations in the affected hemisphere.

CONCLUSIONS

The robotic-based rehabilitation combined with VR in patients with chronic hemiparesis induced an improvement in gait and balance. EEG data suggest that the use of VR may entrain several brain areas (probably encompassing the mirror neuron system) involved in motor planning and learning, thus leading to an enhanced motor performance.

TRIAL REGISTRATION

Retrospectively registered in Clinical Trials on 21-11-2016, n. NCT02971371 .

Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review

BACKGROUND

Virtual reality (VR) based applications play an increasing role in motor rehabilitation. They provide an interactive and individualized environment in addition to increased motivation during motor tasks as well as facilitating motor learning through multimodal sensory information. Several previous studies have shown positive effect of VR-based treatments for lower extremity motor rehabilitation in neurological conditions, but the characteristics of these VR applications have not been systematically investigated. The visual information on the user's movement in the virtual environment, also called movement visualisation (MV), is a key element of VR-based rehabilitation interventions. The present review proposes categorization of Movement Visualisations of VR-based rehabilitation therapy for neurological conditions and also summarises current research in lower limb application.

METHODS

A systematic search of literature on VR-based intervention for gait and balance rehabilitation in neurological conditions was performed in the databases namely; MEDLINE (Ovid), AMED, EMBASE, CINAHL, and PsycInfo. Studies using non-virtual environments or applications to improve cognitive function, activities of daily living, or psychotherapy were excluded. The VR interventions of the included studies were analysed on their MV.

RESULTS

In total 43 publications were selected based on the inclusion criteria. Seven distinct MV groups could be differentiated: indirect MV (N = 13), abstract MV (N = 11), augmented reality MV (N = 9), avatar MV (N = 5), tracking MV (N = 4), combined MV (N = 1), and no MV (N = 2). In two included articles the visualisation conditions included different MV groups within the same study. Additionally, differences in motor performance could not be analysed because of the differences in the study design. Three studies investigated different visualisations within the same MV group and hence limited information can be extracted from one study.

CONCLUSIONS

The review demonstrates that individuals' movements during VR-based motor training can be displayed in different ways. Future studies are necessary to fundamentally explore the nature of this VR information and its effect on motor outcome.

Comparison of a robotic-assisted gait training program with a program of functional gait training for children with cerebral palsy: design and methods of a two group randomized controlled cross-over trial

Background

Enhancement of functional ambulation is a key goal of rehabilitation for children with cerebral palsy (CP) who experience gross motor impairment. Physiotherapy (PT) approaches often involve overground and treadmill-based gait training to promote motor learning, typically as free walking or with body-weight support. Robotic-assisted gait training (RAGT), using a device such as the Lokomat^®Pro, may permit longer training duration, faster and more variable gait speeds, and support walking pattern guidance more than overground/treadmill training to further capitalize on motor learning principles. Single group pre-/post-test studies have demonstrated an association between RAGT and moderate to large improvements in gross motor skills, gait velocity and endurance. A single published randomized controlled trial (RCT) comparing RAGT to a PT-only intervention showed no difference in gait kinematics. However, gross motor function and walking endurance were not evaluated and conclusions were limited by a large PT group drop-out rate.

Methods/design

In this two-group cross-over RCT, children are randomly allocated to the RAGT or PT arm (each with twice weekly sessions for eight weeks), with cross-over to the other intervention arm following a six-week break. Both interventions are grounded in motor learning principles with incorporation of individualized mobility-based goals. Sessions are fully operationalized through manualized, menu-based protocols and post-session documentation to enhance internal and external validity. Assessments occur pre/post each intervention arm (four time points total) by an independent assessor. The co-primary outcomes are gross motor functional ability (Gross Motor Function Measure (GMFM-66) and 6-minute walk test), with secondary outcome measures assessing: (a) individualized goals; (b) gait variables and daily walking amounts; and (c) functional abilities, participation and quality of life. Investigators and statisticians are blinded to study group allocation in the analyses, and assessors are blinded to treatment group. The primary analysis will be the pre- to post-test differences (change scores) of the GMFM-66 and 6MWT between RAGT and PT groups.

Discussion

This study is the first RCT comparing RAGT to an active gait-related PT intervention in paediatric CP that addresses gait-related gross motor, participation and individualized outcomes, and as such, is expected to provide comprehensive information as to the potential role of RAGT in clinical practice.

Trial registration ClinicalTrials.gov NCT02196298

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-3535-0) contains supplementary material, which is available to authorized users.

Evaluation of the effectiveness of robotic gait training and gait-focused physical therapy programs for children and youth with cerebral palsy: a mixed methods RCT

Background

Robot assisted gait training (RAGT) is considered to be a promising approach for improving gait-related gross motor function of children and youth with cerebral palsy. However, RAGT has yet to be empirically demonstrated to be effective. This knowledge gap is particularly salient given the strong interest in this intensive therapy, the high cost of the technology, and the requirement for specialized rehabilitation centre resources.

Methods

This is a research protocol describing a prospective, multi-centre, concurrent mixed methods study comprised of a randomized controlled trial (RCT) and an interpretive descriptive qualitative design. It is a mixed methods study designed to determine the relative effectiveness of three physical therapy treatment conditions (i.e., RAGT, a functional physical therapy program conducted over-ground (fPT), and RAGT + fPT) on gait related motor skills of ambulatory children with cerebral palsy. Children with cerebral palsy aged 5–18 years who are ambulatory (Gross Motor Function Classification System Levels II and III) will be randomly allocated to one of four treatment conditions: 1) RAGT, 2) fPT, 3) RAGT and fPT combined, or 4) a maintenance therapy only control group. The qualitative component will explicate child and parent experiences with the interventions, provide insight into the values that underlie their therapy goals, and assist with interpretation of the results of the RCT.

Discussion

n/a.

Trial Registration

NCT02391324 Registered March 12, 2015.

Gait adaptation to visual kinematic perturbations using a real-time closed-loop brain-computer interface to a virtual reality avatar

OBJECTIVE

The control of human bipedal locomotion is of great interest to the field of lower-body brain-computer interfaces (BCIs) for gait rehabilitation. While the feasibility of closed-loop BCI systems for the control of a lower body exoskeleton has been recently shown, multi-day closed-loop neural decoding of human gait in a BCI virtual reality (BCI-VR) environment has yet to be demonstrated. BCI-VR systems provide valuable alternatives for movement rehabilitation when wearable robots are not desirable due to medical conditions, cost, accessibility, usability, or patient preferences.

APPROACH

In this study, we propose a real-time closed-loop BCI that decodes lower limb joint angles from scalp electroencephalography (EEG) during treadmill walking to control a walking avatar in a virtual environment. Fluctuations in the amplitude of slow cortical potentials of EEG in the delta band (0.1-3 Hz) were used for prediction; thus, the EEG features correspond to time-domain amplitude modulated potentials in the delta band. Virtual kinematic perturbations resulting in asymmetric walking gait patterns of the avatar were also introduced to investigate gait adaptation using the closed-loop BCI-VR system over a period of eight days.

MAIN RESULTS

Our results demonstrate the feasibility of using a closed-loop BCI to learn to control a walking avatar under normal and altered visuomotor perturbations, which involved cortical adaptations. The average decoding accuracies (Pearson's r values) in real-time BCI across all subjects increased from (Hip: 0.18 ± 0.31; Knee: 0.23 ± 0.33; Ankle: 0.14 ± 0.22) on Day 1 to (Hip: 0.40 ± 0.24; Knee: 0.55 ± 0.20; Ankle: 0.29 ± 0.22) on Day 8.

SIGNIFICANCE

These findings have implications for the development of a real-time closed-loop EEG-based BCI-VR system for gait rehabilitation after stroke and for understanding cortical plasticity induced by a closed-loop BCI-VR system.

A Virtual Environment to Improve the Detection of Oral-Facial Malfunction in Children with Cerebral Palsy

The importance of an early rehabilitation process in children with cerebral palsy (CP) is widely recognized. On the one hand, new and useful treatment tools such as rehabilitation systems based on interactive technologies have appeared for rehabilitation of gross motor movements. On the other hand, from the therapeutic point of view, performing rehabilitation exercises with the facial muscles can improve the swallowing process, the facial expression through the management of muscles in the face, and even the speech of children with cerebral palsy. However, it is difficult to find interactive games to improve the detection and evaluation of oral-facial musculature dysfunctions in children with CP. This paper describes a framework based on strategies developed for interactive serious games that is created both for typically developed children and children with disabilities. Four interactive games are the core of a Virtual Environment called SONRIE. This paper demonstrates the benefits of SONRIE to monitor children’s oral-facial difficulties. The next steps will focus on the validation of SONRIE to carry out the rehabilitation process of oral-facial musculature in children with cerebral palsy.

Reliability of timed walking tests and temporo-spatial gait parameters in youths with neurological gait disorders

Background

The 10-Meter Walk Tests (10MWT) and the 6-Minute Walk Test (6MinWT) are applied to assess gait capacity in paediatric patients. To better objectify changes in qualitative aspects of gait, temporo-spatial parameters like stride length or step symmetry could be simultaneously assessed with a GAITRite system. Reliability has not yet been evaluated in a heterogeneous sample of children with various neurological gait disorders such as is representative for paediatric neuro-rehabilitation. The aim of this study was to assess test-retest reliability of the 10MWT, the 6MinWT and simultaneously recorded gait parameters captured with the GAITRite system in children with neurological gait disorders.

Methods

This is a cross-sectional study with two measurement time-points. Thirty participants (9 females; mean (standard deviation) age 13.0 (3.6) years, 10 with cerebral palsy, 6 after stroke, among other diagnoses) performed the 10MWT at preferred (10MWTpref) and maximum speed (10MWTmax) and the 6MinWT on two occasions (mean time interval: 7.0 (1.9) days). Relative reliability was quantified with an intra-class correlation coefficient (ICC); the measurement error reflecting absolute reliability was quantified with the standard error of measurement and the smallest real difference.

Results

ICCs of timed walking tests (time measured with a stopwatch, step count for the 10MWT and walking distance for the 6MinWT) ranged from 0.89–0.97. ICCs of temporo-spatial gait parameters ranged from 0.81–0.95 (10MWTpref), from 0.61–0.90 (10MWTmax) and from 0.88–0.97 (6MinWT). In general, absolute reliability was greatest in the 6MinWT.

Conclusion

Timed walking tests and temporo-spatial gait parameters obtained from the GAITRite system appear reliable in children with neurological gait disorders. However, especially in children with poorer walking ability, the reliability of temporo-spatial parameters might have been positively influenced, as unclear steps had to be removed using the GAITRite software. As absolute reliability is rather low, the responsiveness of these measures needs to be further evaluated.

A Closed-loop Brain Computer Interface to a Virtual Reality Avatar: Gait Adaptation to Visual Kinematic Perturbations

The control of human bipedal locomotion is of great interest to the field of lower-body brain computer interfaces (BCIs) for rehabilitation of gait. While the feasibility of a closed-loop BCI system for the control of a lower body exoskeleton has been recently shown, multi-day closed-loop neural decoding of human gait in a virtual reality (BCI-VR) environment has yet to be demonstrated. In this study, we propose a real-time closed-loop BCI that decodes lower limb joint angles from scalp electroencephalography (EEG) during treadmill walking to control the walking movements of a virtual avatar. Moreover, virtual kinematic perturbations resulting in asymmetric walking gait patterns of the avatar were also introduced to investigate gait adaptation using the closed-loop BCI-VR system over a period of eight days. Our results demonstrate the feasibility of using a closed-loop BCI to learn to control a walking avatar under normal and altered visuomotor perturbations, which involved cortical adaptations. These findings have implications for the development of BCI-VR systems for gait rehabilitation after stroke and for understanding cortical plasticity induced by a closed-loop BCI system.

Stroke Rehabilitation Using Virtual Environments

This review covers the rationale, mechanisms, and availability of commercially available virtual environment-based interventions for stroke rehabilitation. It describes interventions for motor, speech, cognitive, and sensory dysfunction. Also discussed are the important features and mechanisms that allow virtual environments to facilitate motor relearning. A common challenge is the inability to translate success in small trials to efficacy in larger populations. The heterogeneity of stroke pathophysiology has been blamed, and experts advocate for the study of multimodal approaches. Therefore, this article also introduces a framework to help define new therapy combinations that may be necessary to address stroke heterogeneity.

EEG Single-Trial Detection of Gait Speed Changes during Treadmill Walk

In this study, we analyse the electroencephalography (EEG) signal associated with gait speed changes (i.e. acceleration or deceleration). For data acquisition, healthy subjects were asked to perform volitional speed changes between 0, 1, and 2 Km/h, during treadmill walk. Simultaneously, the treadmill controller modified the speed of the belt according to the subject’s linear speed. A classifier is trained to distinguish between the EEG signal associated with constant speed gait and with gait speed changes, respectively. Results indicate that the classification performance is fair to good for the majority of the subjects, with accuracies always above chance level, in both batch and pseudo-online approaches. Feature visualisation and equivalent dipole localisation suggest that the information used by the classifier is associated with increased activity in parietal areas, where mu and beta rhythms are suppressed during gait speed changes. Specifically, the parietal cortex may be involved in motor planning and visuomotor transformations throughout the online gait adaptation, which is in agreement with previous research. The findings of this study may help to shed light on the cortical involvement in human gait control, and represent a step towards a BMI for applications in post-stroke gait rehabilitation.

Rehabilitation Systems Based on Visualization Techniques: A Review

Many efforts are being undertaken in rehabilitation care to improve functions by introducing assist devices. Many such devices make learning more effective by providing the user with augmented feedback on sensor information. Of the several modalities used to achieve this effect, this paper focuses on technological trends in rehabilitation assist devices that use visual feedback. Specifically, the paper deals mainly with devices that use visualization technology to process and display sensor device information.

It's how you get there: walking down a virtual alley activates premotor and parietal areas

Voluntary drive is crucial for motor learning, therefore we are interested in the role that motor planning plays in gait movements. In this study we examined the impact of an interactive Virtual Environment (VE) feedback task on the EEG patterns during robot assisted walking. We compared walking in the VE modality to two control conditions: walking with a visual attention paradigm, in which visual stimuli were unrelated to the motor task; and walking with mirror feedback, in which participants observed their own movements. Eleven healthy participants were considered. Application of independent component analysis to the EEG revealed three independent component clusters in premotor and parietal areas showing increased activity during walking with the adaptive VE training paradigm compared to the control conditions. During the interactive VE walking task spectral power in frequency ranges 8-12, 15-20, and 23-40 Hz was significantly (p ≤ 0.05) decreased. This power decrease is interpreted as a correlate of an active cortical area. Furthermore activity in the premotor cortex revealed gait cycle related modulations significantly different (p ≤ 0.05) from baseline in the frequency range 23-40 Hz during walking. These modulations were significantly (p ≤ 0.05) reduced depending on gait cycle phases in the interactive VE walking task compared to the control conditions. We demonstrate that premotor and parietal areas show increased activity during walking with the adaptive VE training paradigm, when compared to walking with mirror- and movement unrelated feedback. Previous research has related a premotor-parietal network to motor planning and motor intention. We argue that movement related interactive feedback enhances motor planning and motor intention. We hypothesize that this might improve gait recovery during rehabilitation.

Requirements for and impact of a serious game for neuro-pediatric robot-assisted gait training

We investigated whether children with neurological gait disorders who walked in a driven gait orthosis could adjust their participation level according to the demands of a newly developed rehabilitation game. We further investigated if cognitive capacity and motor impairment influenced game performance. Nineteen children with neurological gait disorders (mean age: 13.4 y, 42% girls) participated. To quantify game participation, electromyographic muscle activity (M. rectus femoris) and heart rate were compared in a demanding part and a less demanding part of the game. Cognitive capacity was assessed with the Test of Nonverbal Intelligence (TONI-4). Furthermore, the Functional Independence Measure for Children (WeeFIM), Manual Muscle Tests and a therapist-derived score of how well the child was able to train were assessed. Results showed that muscle activity and heart rate were higher during the demanding part of the game (30.7 ± 22.6 μV; 129.4 ± 15.7 bpm) compared to the less demanding part (16.0 ± 13.4 μV; 124.1 ± 15.9 bpm; p<0.01 for both measures). Game performance correlated moderately with the TONI-4 (r=0.50, p=0.04) and the cognition subscale of the WeeFIM (ρ=0.59, p=0.01). The therapist-derived score correlated significantly with game performance (p=0.75, p<0.01) and the ability to modify muscle activity to the demands of the game (p=-0.72, p<0.01). Receiver operating characteristic analyses revealed that the latter factor differentiated well between those children suitable for the game and those not. We conclude that children with neurological gait disorders are able to modify their activity to the demands of the VR-scenario. However, cognitive function and motor impairment determine to which extent. These results are important for clinical decision-making.