Virtual reality experiences, embodiment, videogames and their dimensions in neurorehabilitation

Effectiveness of virtual reality in preventing falls in non-disabled older adults: A meta-analysis and systematic review

OBJECTIVE

This study was conducted to evaluate the effectiveness of virtual reality interventions in preventing falls among non-disabled older adults.

METHODS

We conducted a librarian-designed database search. Two researchers independently screened eligible studies. The Cochrane Handbook for Systematic Reviews of Interventions was used to assess the risk of bias in the included studies.

RESULTS

Virtual reality interventions can effectively improve gait and dynamic and static balance function, enhance lower limb muscle strength, and reduce the risk of falls in the non-disabled elderly. However, the effect of virtual reality on reducing the fear of falling remains controversial.

CONCLUSION

Virtual reality interventions can effectively prevent falls in nondisabled elderly individuals. Higher quality, larger sample size, and long-term follow-up studies are needed to further verify the long-term effectiveness of virtual reality training in preventing falls in non-disabled elderly individuals.

Virtual Reality During Chemotherapy Infusion: An Innovative Intervention in Holistic Nursing Practice

Patients with cancer receiving infusional chemotherapy show negative symptoms such as worry about their survival, anxiety, anguish, depression, fear, magnified perception of the passage of time, and difficulty managing boredom. Patients also suffer various side effects produced by chemotherapy such as nausea, vomiting, pain, and fatigue, which, together with psychological distress, drastically reduce their quality of life and adherence to therapy with a corresponding reduction in the probability of the individual's survival. Virtual Reality is one of the most innovative and promising digital health interventions, capable of quickly and effectively producing a positive influence on the psychosomatic axis, improving patients' quality of life during chemotherapy. Virtual Reality, through its 3-dimensional multisensory technology, isolates sensory channels from the negative external environment and enables an experience of being physically and psychologically present within virtual scenarios, in which patients can perceive sensations, emotions, cognitions, and interactions as if they really were in different surroundings. This article systematically expounds the scientific conditions necessary for effective, appropriate, and safe implementation of Virtual Reality interventions in holistic nursing practice, describing the underpinning conceptual framework, the types, technological characteristics, methods of use, duration, type of virtual content, and implementation procedure of Virtual Reality.

Feasibility of an exercise-nutrition-psychology integrated rehabilitation model based on mobile health and virtual reality for cancer patients: a single-center, single-arm, prospective phase II study

OBJECTIVE

Explore the feasibility of a mobile health(mHealth) and virtual reality (VR) based nutrition-exercise-psychology integrated rehabilitation model in Chinese cancer patients.

METHODS

We recruited cancer patients in the Oncology department of the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University from October 2022 to April 2023. The rehabilitation program was provided by a team of medical oncologists, dietitians, psychotherapists, and oncology specialist nurses. Participants received standard anti-cancer therapy and integrated intervention including hospitalized group-based exercise classes, at-home physical activity prescription, behavior change education, oral nutrition supplements, and psychological counseling. An effective intervention course includes two consecutive hospitalization and two periods of home-based rehabilitation (8 weeks). Access the feasibility as well as changes in aspects of physical, nutritional, and psychological status.

RESULTS

At the cutoff date of April 2023, the recruitment rate was 75% (123/165). 11.4%patients were lost to follow-up, and 3.25% withdrew halfway. Respectively, the completion rate of nutrition, exercise, and psychology were 85%,55%, and 63%. Nutrition interventions show the highest compliance. The parameters in nutrition, psychology, muscle mass, and quality of life after the rehabilitation showed significant improvements (P < .05). There was no significant statistical difference (P > .05) in handgrip strength and 6-minute walking speed.

CONCLUSION

It is feasible to conduct mHealth and VR-based nutrition-exercise-psychology integrated rehabilitation model in Chinese cancer patients. A larger multi-center trial is warranted in the future.

TRIAL REGISTRATION

ChiCTR2200065748 Registered 14 November 2022.

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

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

Comparing Walking-Related Everyday Life Tasks of Children with Gait Disorders in a Virtual Reality Setup With a Physical Setup: Cross-Sectional Noninferiority Study

BACKGROUND

A frequent rehabilitation goal for children with gait disorders is to practice daily-life walking activities. Unfortunately, these are often difficult to practice in a conventional therapeutic setting. Virtual reality (VR) with head-mounted displays (HMDs) could be a promising approach in neurorehabilitation to train such activities in a safe environment. First, however, we must know whether obstacles in VR are indeed mastered as obstacles.

OBJECTIVE

This study aimed to provide information on whether VR is feasible and motivating to induce and practice movements needed to master real obstacles in children and adolescents with gait disorders. Furthermore, this project aims to evaluate which kinds of everyday walking activities are appropriate to be practiced in VR.

METHODS

In this cross-sectional study, participants stepped over a bar, crossed a gap, balanced over a beam, and circumvented stationary obstructions arranged in a course under real physical and virtual conditions wearing a VR HMD. We recorded the respective primary outcomes (step height, step length, step width, and minimal shoulder-obstacle distance) with motion capture. We then calculated the mean differences and 95% CI of the spatiotemporal parameters between the VR and physical setup and later compared them using noninferiority analysis with margins defined a priori by a clinical expert panel. Additionally, the participants responded to a standardized questionnaire while the therapists observed and evaluated their movement performance.

RESULTS

We recruited 20 participants (mean age 12.0, range 6.6-17.8 years) with various diagnoses affecting their walking ability. At 3.77 (95% CI 1.28 to 6.26) cm, the mean difference in step height of the leading foot in the overstepping task did not exceed the predefined margin of -2 cm, thus signifying noninferiority of the VR condition compared to mastering the physical obstacles. The same was true for step length (-1.75, 95% CI -4.91 to 1.41 cm; margin -10 cm), step width (1.05, 95% CI 0.20 to -1.90 cm; margin 3 cm), and the minimal shoulder-obstacle distance (0.25, 95% CI -0.85 to 0.35 cm; margin -2 cm) in the other tasks. Only the trailing foot in the overstepping task yielded inconclusive results.

CONCLUSIONS

Children with gait disorders perform everyday walking tasks like overstepping, crossing, balancing, or circumventing similarly in physical and VR environments, suggesting that VR could be a feasible therapeutic tool to practice everyday walking tasks.

Rehabilitation via HOMe-Based gaming exercise for the Upper limb post Stroke (RHOMBUS): a qualitative analysis of participants' experience

OBJECTIVE

To report participants' experiences of trial processes and use of the Neurofenix platform for home-based rehabilitation following stroke. The platform, consisting of the NeuroBall device and Neurofenix app, is a non-immersive virtual reality tool to facilitate upper limb rehabilitation following stroke. The platform has recently been evaluated and demonstrated to be safe and effective through a non-randomised feasibility trial (RHOMBUS).

DESIGN

Qualitative approach using semistructured interviews. Interviews were audio recorded, transcribed verbatim and analysed using the framework method.

SETTING

Participants' homes, South-East England.

PARTICIPANTS

Purposeful sample of 18 adults (≥18 years), minimum 12 weeks following stroke, not receiving upper limb rehabilitation prior to the RHOMBUS trial, scoring 9-25 on the Motricity Index (elbow and shoulder), with sufficient cognitive and communicative abilities to participate.

RESULTS

Five themes were developed which explored both trial processes and experiences of using the platform. Factors that influenced participant's decision to take part in the trial, their perceptions of support provided during the trial and communication with the research team were found to be important contextual factors effecting participants' overall experience. Specific themes around usability and comfort of the NeuroBall device, factors motivating persistence and perceived effectiveness of the intervention were highlighted as being central to the usability and acceptability of the platform.

CONCLUSION

This study demonstrated the overall acceptability of the platform and identified areas for enhancement which have since been implemented by Neurofenix. The findings add to the developing literature on the interface between virtual reality systems and user experience.

TRIAL REGISTRATION NUMBER

ISRCTN60291412.

Virtual reality working memory training improves cognitive performance of acute and remitted patients with major depressive disorder

BACKGROUND

Cognitive training is effective in treating neuropsychological impairment in patients with major depressive disorder (MDD), and virtual reality (VR) is a promising tool to provide such training. However, studies using VR-based working memory (WM) training in treating depressed patients' cognitive impairment are extremely scarce and how it affects cognitive performance remains unclear. Therefore, we aimed to determine the efficacy of VR-WM training in acute and remitted depressed patients and try to investigate its potential mechanisms.

METHODS

Forty-two patients with MDD (22 acute patients and 20 remitted patients) received 20-session VR-WM training, while 22 healthy controls (HC) received no intervention. WM and other cognitive domains' performance were assessed by the Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire (CPFQ) and the MATRICS Consensus Cognitive Battery (MCCB) before and after the intervention. Depressive symptoms were assessed by the 24-item Hamilton Depression Rating Scale (24-HDRS) at the same time points.

RESULTS

Acute and remitted MDD patients both exhibited significant improvements from pre- to post-training in WM, processing speed, visual learning, reasoning and problem-solving, and total cognition (all p < 0.05). Significant groups-by-time interactions were observed for the 24-HDRS score (p < 0.05). Mediation analysis showed that 24-HDRS score partially mediated the association between the effect of VR-WM training on WM and total cognition performance in total depressive samples.

CONCLUSIONS

VR-WM training effectively improved WM and other cognitive domains' performance in both acute and remitted MDD patients. Besides, VR-WM training improves WM and total cognition performance in MDD patients partially via the enhancement of depressive symptoms.

The Immediate Effects of Immersive Virtual Reality on Autonomic Nervous System Function in Patients with Disorders of Consciousness after Severe Acquired Brain Injury: A Pilot Study

Disorders of Consciousness (DoCs) after severe acquired brain injury involve substantial impairment of cognition and physical functioning, requiring comprehensive rehabilitation and support. Technological interventions, such as immersive Virtual Reality (VR), have shown promising results in promoting neural activity and enhancing cognitive and motor recovery. VR can induce physical sensations that may activate the Autonomic Nervous System (ANS) and induce ANS-regulated responses. This study aimed to investigate the effects of immersive VR on the ANS in patients with DoCs through the analysis of the electrodermal activity (EDA). EDA was measured with a wearable device during a single immersive VR session consisting of static and dynamic videos depicting naturalistic environments. A pilot case-control study was conducted with 12 healthy participants and 12 individuals with DoCs. Results showed higher EDA values in patients than in healthy participants (p = 0.035), suggesting stronger autonomic activation during immersive VR exposure, while healthy subjects, in turn, showed a decrease in EDA values. Our results revealed a significant interaction between conditions and groups (p = 0.003), with patients showing significantly increased EDA values from the baseline compared to dynamic video observation (p = 0.014) and final rest (p = 0.007). These results suggest that immersive VR can elicit sympathetic arousal in patients with DoCs. This study highlights the potential of immersive VR as a tool to strengthen autonomic responses in patients with impaired consciousness.

Performance Evaluation of an Immersive Virtual Reality Application for Rehabilitation after Arthroscopic Rotator Cuff Repair

Few studies have evaluated the effectiveness of shoulder rehabilitation in virtual environments. The objective of this study was to investigate the performance of a custom virtual reality application (VR app) with a stereophotogrammetric system considered the gold standard. A custom VR app was designed considering the recommended rehabilitation exercises following arthroscopic rotator cuff repair. Following the setting of the play space, the user's arm length, and height, five healthy volunteers performed four levels of rehabilitative exercises. Results for the first and second rounds of flexion and abduction displayed low total mean absolute error values and low numbers of unmet conditions. In internal and external rotation, the number of times conditions were not met was slightly higher; this was attributed to a lack of isolated shoulder movement. Data is promising, and volunteers were able to reach goal conditions more often than not. Despite positive results, more literature comparing VR applications with gold-standard clinical parameters is necessary. Nevertheless, results contribute to a body of literature that continues to encourage the application of VR to shoulder rehabilitation programs.

Development of a Core Set of Quality Criteria for Virtual Reality Applications Designed for Older Adults: Multistep Qualitative Study

BACKGROUND

Virtual reality (VR) applications are gaining growing significance, particularly among older adults. These applications can provide valuable support to older adults by offering immersive VR content that positively influences various aspects of their daily lives, including activities of daily living. Furthermore, VR applications can contribute to the enhancement of cognitive and motor skills, ultimately leading to an improved quality of life for older individuals. Nevertheless, to ensure a positive impact, it is crucial to develop VR experiences that are tailored to the needs and preferences of the users.

OBJECTIVE

This study aims to develop a core set of quality criteria and guidelines for the development of user-centered VR applications specifically designed for older adults (target group).

METHODS

The multistep qualitative study design comprised several key stages, beginning with a systematic literature search. This was followed by a framework analysis aimed at identifying a core set of criteria. Subsequently, these criteria underwent validation through expert workshops. The outcomes achieved through this iterative process were organized and categorized into criteria, accompanied by explanations detailing the underlying categories or codes.

RESULTS

The quality criteria core set for older adults-friendly VR applications has been developed through an iterative process. It is divided into 2 distinct parts, each containing criteria categorized into specific areas. The first part includes the following categories: (1) quality assurance of medical/health content, (2) data protection provisions, (3) quality requirements, (4) consumer protection, and (5) interoperability. The second part includes the following categories: (1) graphic/quality, (2) 3D character/avatar, (3) providing in-game instructions and prompts, (4) interaction, (5) navigation, and (6) promotion of user motivation and loyalty to use. The results imply a differentiated scope as well as a differentiated granularity of the criteria.

CONCLUSIONS

Considering the ongoing advancement of VR technology and the diverse needs within the older adult demographic, it is essential to assess the quality criteria core set results on an individual basis.

Bill-EVR: An Embodied Virtual Reality Framework for Reward-and-Error-Based Motor Rehab-Learning

VR rehabilitation is an established field by now, however, it often refers to computer screen-based interactive rehabilitation activities. In recent years, there was an increased use of VR-headsets, which can provide an immersive virtual environment for real-world tasks, but they are lacking any physical interaction with the task objects and any proprioceptive feedback. Here, we focus on Embodied Virtual Reality (EVR), an emerging field where not only the visual input via VR-headset but also the haptic feedback is physically correct. This happens because subjects interact with physical objects that are veridically aligned in Virtual Reality. This technology lets us manipulate motor performance and motor learning through visual feedback perturbations. Bill-EVR is a framework that allows interventions in the performance of real-world tasks, such as playing pool billiard, engaging end-users in motivating life-like situations to trigger motor (re)learning - subjects see in VR and handle the real-world cue stick, the pool table and shoot physical balls. Specifically, we developed our platform to isolate and evaluate different mechanisms of motor learning to investigate its two main components, error-based and reward-based motor adaptation. This understanding can provide insights for improvements in neurorehabilitation: indeed, reward-based mechanisms are putatively impaired by degradation of the dopaminergic system, such as in Parkinson's disease, while error-based mechanisms are essential for recovering from stroke-induced movement errors. Due to its fully customisable features, our EVR framework can be used to facilitate the improvement of several conditions, providing a valid extension of VR-based implementations and constituting a motor learning tool that can be completely tailored to the individual needs of patients.

Virtual reality simulator's effectiveness on the spine procedure education for trainee: a randomized controlled trial

BACKGROUND

Since the onset of the coronavirus disease 2019 pandemic, virtual simulation has emerged as an alternative to traditional teaching methods as it can be employed within the recently established contact-minimizing guidelines. This prospective education study aimed to develop a virtual reality simulator for a lumbar transforaminal epidural block (LTFEB) and demonstrate its efficacy.

METHODS

We developed a virtual reality simulator using patient image data processing, virtual X-ray generation, spatial registration, and virtual reality technology. For a realistic virtual environment, a procedure room, surgical table, C-arm, and monitor were created. Using the virtual C-arm, the X-ray images of the patient's anatomy, the needle, and indicator were obtained in real-time. After the simulation, the trainees could receive feedback by adjusting the visibility of structures such as skin and bones. The training of LTFEB using the simulator was evaluated using 20 inexperienced trainees. The trainees' procedural time, rating score, number of C-arm taken, and overall satisfaction were recorded as primary outcomes.

RESULTS

The group using the simulator showed a higher global rating score (P = 0.014), reduced procedural time (P = 0.025), reduced number of C-arm uses (P = 0.001), and higher overall satisfaction score (P = 0.007).

CONCLUSIONS

We created an accessible and effective virtual reality simulator that can be used to teach inexperienced trainees LTFEB without radiation exposure. The results of this study indicate that the proposed simulator will prove to be a useful aid for teaching LTFEB.

FitJaw Mobile, a virtual reality device applied to dentistry: An analysis based on two patient treatments

STATEMENT OF PROBLEM

Virtual reality (VR) has improved significantly in the last decade and has been applied to different fields, including medicine, dentistry, and physiotherapy. VR has been used for the innovative treatment of painful conditions, especially when traditional exercise therapies were unsuccessful because of patient noncompliance.

PURPOSE

The purpose of this study was to analyze the use of VR as an aid when using exercises to manage temporomandibular disorders (TMDs).

MATERIAL AND METHODS

Two White women diagnosed with TMDs of muscular origin (one with muscular pain and the other with reduced mouth opening) were referred to the Department of Prosthodontics of the University of Seville, where they were enrolled in an exercise program using the VR software program FitJaw Mobile. Both had been treated the previous year with an occlusal device for TMD of muscular origin, but their symptoms had not improved.

RESULTS

For both patients, the functional movement limitation and the chronic pain improved noticeably.

CONCLUSIONS

The use of VR when doing jaw exercises can improve outcomes and compliance.

Effect of a Virtual Reality-Mediated Gamified Rehabilitation Program on Upper Limb Functions in Children With Hemiplegic Cerebral Palsy: A Prospective, Randomized Controlled Study

OBJECTIVE

The aim of the study is to investigate the effects of a virtual reality-mediated gamified rehabilitation program on upper limb functions, skills, range of motion, muscle tone, and quality of life in children with hemiplegic cerebral palsy.

DESIGN

This prospective, randomized, and controlled study included 36 children with hemiplegic cerebral palsy. Children were randomized into two groups, the virtual reality group ( n = 18) and the control group ( n = 18). Stretching and range-of-motion exercises were performed on the affected upper limb of the children in both groups. In addition to this exercise program, in the virtual reality group, virtual reality-mediated upper limb rehabilitation was performed under supervision. The children were assessed at baseline and 1 and 3 mos after the intervention.

RESULTS

There was a significant increase in Assisting Hand Assessment, ABILHAND-Kids, Quality of Upper Extremity Skills Test, and KINDL values in the virtual reality group. In addition, there were significant increases in the active joint range of motion of the finger flexion, wrist flexion, pronation, and supination in the virtual reality group.

CONCLUSIONS

In this study, it was determined that upper limb function, quality of life, and active joint range of motion of the children with hemiplegic cerebral palsy were increased with virtual reality-mediated upper limb rehabilitation.

Can Virtual Reality-Assisted Therapy Offer Additional Benefits to Patients With Vestibular Disorders Compared With Conventional Vestibular Physical Therapy? A Meta-analysis

OBJECTIVE

To determine whether virtual reality-assisted therapy (VRAT) significantly improves the treatment of peripheral or central vestibular disorders when compared with conventional vestibular physical therapy (CVPT) alone. Indicators of vestibular symptoms are used to determine this.

DATA SOURCES

Two reviewers independently searched PubMed, EMBASE, ClinicalTrials.gov, Web of Science, and the Cochrane Collaboration database from January 2010 to January 2022 for studies reporting on VRAT in vestibular disorders.

STUDY SELECTION

Randomized controlled trials (RCTs) were included that mainly focused on the following measures: the Dizziness Handicap Inventory (DHI), Simulator Sickness Questionnaire, visual analog scale, and balance measures such as the Activities-specific Balance Confidence Scale (ABC), timed Up and Go test, sensory organization test, and center of pressure. The primary outcome was assessment of symptomatic changes before and after VRAT.

DATA EXTRACTION

Two authors independently conducted the literature search and selection. After screening, meta-analysis was performed on the RCTs using RevMan 5.3 software.

DATA SYNTHESIS

The results showed that VRAT produced significantly greater improvement than CVPT alone in scores of DHI-Total (standardized mean difference [SMD]: -7.09, 95% confidence interval [CI]: [-12.17, -2.00], P=.006), DHI-Functional (SMD=-3.66, 95% CI: [-6.34, -0.98], P=.007), DHI-Physical (SMD=-3.14, 95% CI: [-5.46, -0.83], P=.008), and DHI-Emotional (SMD=-3.10, 95% CI: [-5.13, -1.08], P=.003). ABC scores did not show improvement (SMD: 0.58, 95% CI: [-3.69, 4.85], P=.79). Subgroup analysis showed that DHI-Total between-group differences were insignificant for central vestibular disorders (SMD=-1.47, 95% CI: [-8.71, -5.78], P=.69), although peripheral disorders showed significant improvements (SMD=-9.58, 95% CI: [-13.92, -5.25], P<.0001). However, the included studies showed high heterogeneity (I²>75%).

CONCLUSIONS

VRAT may offer additional benefits for rehabilitation from vestibular diseases, especially peripheral disorders, when compared with CVPT alone. However, because of high heterogeneity and limited data, additional studies with a larger sample size and more sensitive and specific measurements are required to conclusively determine the evidence-based utility of virtual reality.

From digital museuming to on-site visiting: The mediation of cultural identity and perceived value

Introduction

Museums use digital resources to provide online services to the public, and a "digital museuming" boom has started. The mechanism of online museum visiting and its impact on willingness to visit on site has become an important issue of widespread concern. Therefore, based on the theory of presence and cognitive-emotional-behavioral theory, this paper introduces perceived value and cultural identity as mediating variables to explore the influence of the digital museuming experience on the willingness to visit on site from the audience's perspective.

Method

Questionnaires were distributed, using the snowball sampling method, and 429 valid questionnaires were returned.

Results

The empirical test presents the following results: (1) virtual reality technology multi-dimensionally expands the digital museuming experience; (2) immersion, interaction and available experience promote willingness to visit on-site; (3) hedonic experience in the process of digital museuming cannot be ignored; and (4) perceived value and cultural identity play a mediating role.

Discussion

User experience of visiting virtual museums, perceived value and cultural identity influence user willingness to visit museums in the field, but perceived value does not enhance the user's cultural identity, maybe due to the inability of the online experience to increase the depth of the experience.

Combining physical and virtual worlds for motor-cognitive training interventions: Position paper with guidelines on technology classification in movement-related research

Efficient movements require intact motor and cognitive function. There is a growing literature on motor-cognitive interventions to improve the overall quality of life of healthy or diseased older people. For such interventions, novel technological advances are crucial not only in terms of motivation but also to improve the user experience in a multi-stimuli world, usually offered as a mixture of real and virtual environments. This article provides a classification system for movement-related research dealing with motor-cognitive interventions performed in different extents of a virtual environment. The classification is divided into three categories: (a) type of digital device with the associated degree of immersiveness provided; (b) presence or absence of a human-computer interaction; and (c) activity engagement during training, defined by activity >1.5 Metabolic Equivalent of task. Since virtual reality (VR) often categorizes different technologies under the same term, we propose a taxonomy of digital devices ranging from computer monitors and projectors to head-mounted VR technology. All immersive technologies that have developed rapidly in recent years are grouped under the umbrella term Extended Reality (XR). These include augmented reality (AR), mixed reality (MR), and VR, as well as all technologies that have yet to be developed. This technology has potential not only for gaming and entertainment, but also for research, motor-cognitive training programs, rehabilitation, telemedicine, etc. This position paper provides definitions, recommendations, and guidelines for future movement-related interventions based on digital devices, human-computer interactions, and physical engagement to use terms more consistently and contribute to a clearer understanding of their implications.

Altered effective connectivity in the emotional network induced by immersive virtual reality rehabilitation for post-stroke depression

Post-stroke depression (PSD) is a serious complication of stroke that significantly restricts rehabilitation. The use of immersive virtual reality for stroke survivors is promising. Herein, we investigated the effects of a novel immersive virtual reality training system on PSD and explored induced effective connectivity alterations in emotional networks using multivariate Granger causality analysis (GCA). Forty-four patients with PSD were equally allocated into an immersive-virtual reality group and a control group. In addition to their usual rehabilitation treatments, the participants in the immersive-virtual reality group participated in an immersive-virtual reality rehabilitation program, while the patients in the control group received 2D virtual reality rehabilitation training. The Hamilton Depression Rating Scale, modified Barthel Index (MBI), and resting-state functional magnetic resonance imaging (rsfMRI) data were collected before and after a 4-week intervention. rsfMRI data were analyzed using multivariate GCA. We found that the immersive virtual reality training was more effective in improving depression in patients with PSD but had no statistically significant improvement in MBI scores compared to the control group. The GCA showed that the following causal connectivities were strengthened after immersive virtual reality training: from the amygdala, insula, middle temporal gyrus, and caudate nucleus to the dorsolateral prefrontal cortex; from the insula to the medial prefrontal cortex; and from the thalamus to the posterior superior temporal sulcus. These causal connectivities were weakened after treatment in the control group. Our results indicated the neurotherapeutic use of immersive virtual reality rehabilitation as an effective non-pharmacological intervention for PSD; the alteration of causal connectivity in emotional networks might constitute the neural mechanisms underlying immersive-virtual reality rehabilitation in PSD.

Virtual Reality Rehabilitation Systems for Cancer Survivors: A Narrative Review of the Literature

Rehabilitation plays a crucial role in cancer care, as the functioning of cancer survivors is frequently compromised by impairments that can result from the disease itself but also from the long-term sequelae of the treatment. Nevertheless, the current literature shows that only a minority of patients receive physical and/or cognitive rehabilitation. This lack of rehabilitative care is a consequence of many factors, one of which includes the transportation issues linked to disability that limit the patient’s access to rehabilitation facilities. The recent COVID-19 pandemic has further shown the benefits of improving telemedicine and home-based rehabilitative interventions to facilitate the delivery of rehabilitation programs when attendance at healthcare facilities is an obstacle. In recent years, researchers have been investigating the benefits of the application of virtual reality to rehabilitation. Virtual reality is shown to improve adherence and training intensity through gamification, allow the replication of real-life scenarios, and stimulate patients in a multimodal manner. In our present work, we offer an overview of the present literature on virtual reality-implemented cancer rehabilitation. The existence of wide margins for technological development allows us to expect further improvements, but more randomized controlled trials are needed to confirm the hypothesis that VRR may improve adherence rates and facilitate telerehabilitation.

Exploring Biomimetic Stiffness Modulation and Wearable Finger Haptics for Improving Myoelectric Control of Virtual Hand

The embodiment of virtual hand (VH) by the user is generally deemed to be important for virtual reality (VR) based hand rehabilitation applications, which may help to engage the user and promote motor skill relearning. In particular, it requires that the VH should produce task-dependent interaction behaviors from rigid to soft. While such a capability is inherent to humans via hand stiffness regulation and haptic interactions, yet it have not been successfully imitated by VH in existing studies. In this paper, we present a work which integrates biomimetic stiffness regulation and wearable finger force feedback in VR scenarios involving myoelectric control of VH. On one hand, the biomimetic stiffness modulation intuitively enables VH to imitate the stiffness profile of the user's hand in real time. On the other hand, the wearable finger force-feedback device elicits a natural and realistic sensation of external force on the fingertip, which provides the user a proper understanding of the environment for enhancing his/her stiffness regulation. The benefits of the proposed integrated system were evaluated with eight healthy subjects that performed two tasks with opposite stiffness requirements. The achieved performance is compared with reduced versions of the integrated system, where either biomimetic impedance control or wearable force feedback is excluded. The results suggest that the proposed integrated system enables the stiffness of VH to be adaptively regulated by the user through the perception of interaction torques and vision, resulting in task-dependent behaviors from rigid to soft for VH.

Enhance VR: A Multisensory Approach to Cognitive Training and Monitoring

Cognitive training systems aim to improve specific domains or global cognition by engaging users in cognitively demanding tasks. While screen-based applications can improve performance in the trained cognitive abilities, they are often criticized for their poor transferability to activities of daily living. These systems, however, exclude the user's body and motor skills, which invariably serves to restrict the user experience. Immersive Virtual Reality (IVR) systems, in contrast, present the user with body-related information, such as proprioceptive and visuomotor information, allowing for an immersive and embodied experience of the environment. This feature renders VR a very appealing tool for cognitive training and neurorehabilitation applications. We present Enhance VR, an IVR-based cognitive training and monitoring application that offers short daily cognitive workouts. The games are designed to train and monitor specific cognitive domains such as memory, task flexibility, information processing, orientation, attention, problem-solving, and motor control. The aim is to test whether cognitively demanding tasks, presented in an IVR setting, provide a naturalistic system to train and monitor cognitive capabilities.

Virtual reality is a promising therapy tool for walking activities in pediatric neurorehabilitation: Evaluation of usability and user experience (Preprint)

Background

Objective

Methods

Results

Conclusions

The effects of virtual reality training in stroke and Parkinson's disease rehabilitation: a systematic review and a perspective on usability

Background

Virtual Reality (VR) training is emerging in the neurorehabilitation field. Technological advancement is often faster than clinical implementation. Previous reviews stressed the study design and methodological weaknesses of research in the field of VR for neurorehabilitation. Clinically relevant conclusions on implementation in particular patient groups are needed.

The aim was to update the existing knowledge with the recent evidence on the effects of VR training on functional ability of patients with stroke and Parkinson’s Disease (PD). Secondary objective was to analyze the aspects of usability of VR intervention in these populations.

Methods

Systematic literature search (via PubMed, CENTRAL) was conducted from inception to February 29, 2020 to identify suitable articles for two population subcategories. Randomized controlled trials published from 2016 to 2020, investigating the effectiveness of VR on a variety of outcomes contributing to the functional independence were included. Critical Appraisal Skills Programme (CASP) checklist was used for a methodological quality assessment of the primary studies. Given the heterogeneity in types of VR intervention and outcomes, a descriptive synthesis was conducted.

Results

A total of 18 randomized controlled trials were included (10 in stroke subcategory, 8 in PD). CASP grading ranged 9–11, suggesting high methodological quality. All studies concluded that overall VR might be as effective as the conventional training, but more motivating. In some studies, VR was found to have a greater effect, taking the high response to treatment and satisfaction into account.

Conclusions

VR training is suggested as an effective intervention to improve the functional ability in stroke and PD patients. Addition of VR into a rehabilitation program might facilitate patient’s motivation, participation and improvement, as this method was generally well accepted, and the results of trials were promising. The consideration of disorder-specific aspects should take place during the decision-making of VR implementation.

Upper limb rehabilitation system based on virtual reality for breast cancer patients: Development and usability study

Background

Functional exercise is crucial for breast cancer patients after surgery, and the use of virtual reality technology to assist patients with postoperative upper limb functional rehabilitation has gradually attracted the attention of researchers. However, the usability of the developed rehabilitation system is still unknown to a large extent. The purpose of this study was to develop a virtual reality upper limb rehabilitation system for patients after breast cancer surgery and to explore its usability.

Methods

We built a multidisciplinary team based on virtual reality and human-computer interaction technology and designed and developed an upper limb function rehabilitation system for breast cancer patients after surgery. Breast cancer patients were recruited from a grade III-a general hospital in Changchun city for the experiment. We used the System Usability Scale to evaluate the system availability, the Presence Questionnaire scale to measure the immersive virtual reality scene, and the Simulator Sickness Questionnaire subjective measurement scale for simulator sickness symptoms.

Results

This upper limb rehabilitation system hardware consisted of Head-mounted Display, a control handle and notebook computers. The software consisted of rehabilitation exercises and game modules. A total of 15 patients were tested on this system, all of whom were female. The mean age was 54.73±7.78 years, and no patients were excluded from the experiment because of adverse reactions such as dizziness and vomiting. The System Usability Scale score was 90.50±5.69, the Presence Questionnaire score was 113.40±9.58, the Simulator Sickness Questionnaire-nausea score was 0.93±1.16, the Simulator Sickness Questionnaire-oculomotor score was 0.80±1.27, the Simulator Sickness Questionnaire-disorientation score was 0.80±1.27, and the Simulator Sickness Questionnaire total score was 2.53±3.40.

Conclusions

This study fills in the blanks regarding the upper limb rehabilitation of breast cancer patients based on virtual reality technology system usability research. As the starting point of research in the future, we will improve the system’s function and design strictly randomized controlled trials, using larger samples in the promotion, to evaluate its application in breast cancer patients with upper limbs and other physiological functions and the feasibility and effects of rehabilitation.

DO YOUTHS WITH NEUROMOTOR DISORDER AND THEIR THERAPISTS PREFER A MIXED OR VIRTUAL REALITY HEAD-MOUNTED DISPLAY?

Objective

To evaluate the usability of 2 head-mounted displays in youths undergoing neurorehabilitation; a mixed reality head-mounted display and a virtual reality head-mounted display.

Design

Observational cross-sectional study.

Patients

Thirteen youths (age range 7.8–16.5 years) with neuromotor disorder.

Methods

Youths wore a mixed reality or a virtual reality head-mounted display while being verbally guided through a scene with virtual objects. Differences between the 2 systems, regarding usability, user experience, and acceptability, were evaluated using standardized questions for the youths and their therapists. System preferences and symptoms of cybersickness were noted.

Results

Both head-mounted displays were easy to mount and adjust to the children’s heads, but the mixed reality system was unstable in 40% of the youths. Participants stated that they could move naturally with both devices. Object appearance scored higher with the virtual reality system, while therapists rated youths’ movement execution and needed additional support in favour of the mixed reality system. Most youths preferred the virtual reality device, mainly due to the more distinct appearance of objects and the objects’ richer colours. Therapists’ preferences were balanced. Two children reported minimal signs of cybersickness.

Conclusion

Youths and therapists accepted both systems well, with advantages regarding usability, user experience, and preference for the virtual reality, and acceptability for the mixed reality head-mounted display.

Theoretical Rationale for Design of Tasks in a Virtual Reality-Based Exergame for Rehabilitation Purposes

Virtual reality games are playing a greater role in rehabilitation settings. Previously, commercial games have dominated, but increasingly, bespoke games for specific rehabilitation contexts are emerging. Choice and design of tasks for VR-games are still not always clear, however; some games are designed to motivate and engage players, not necessarily with the facilitation of specific movements as a goal. Other games are designed specifically for the facilitation of specific movements. A theoretical background for the choice of tasks seems warranted. As an example, we use a game that was designed in our lab: VR Walk. Here, the player walks on a treadmill while wearing a head-mounted display showing a custom-made virtual environment. Tasks include walking on a glass bridge across a drop, obstacle avoidance, narrowing path, walking in virtual footsteps, memory, and selection tasks, and throwing and catching objects. Each task is designed according to research and theory from movement science, exercise science, and cognitive science. In this article, we discuss how for example walking across a glass bridge gives perceptual challenges that may be suitable for certain medical conditions, such as hearing loss, when perceptual abilities are strained to compensate for the hearing loss. In another example, walking in virtual footsteps may be seen as a motor and biomechanical constraint, where the double support phase and base of support can be manipulated, making the task beneficial for falls prevention. In a third example, memory and selection tasks may challenge individuals that have cognitive impairments. We posit that these theoretical considerations may be helpful for the choice of tasks and for the design of virtual reality games.

Serious Game Design and Clinical Improvement in Physical Rehabilitation: Systematic Review

Background

Serious video games have now been used and assessed in clinical protocols, with several studies reporting patient improvement and engagement with this type of therapy. Even though some literature reviews have approached this topic from a game perspective and presented a broad overview of the types of video games that have been used in this context, there is still a need to better understand how different game characteristics and development strategies might impact and relate to clinical outcomes.

Objective

This review assessed the relationship between the characteristics of serious games (SGs) and their relationship with the clinical outcomes of studies that use this type of therapy in motor impairment rehabilitation of patients with stroke, multiple sclerosis, or cerebral palsy. The purpose was to take a closer look at video game design features described in the literature (game genre [GG], game nature [GN], and game development strategy [GDS]) and assess how they may contribute toward improving health outcomes. Additionally, this review attempted to bring together medical and game development perspectives to facilitate communication between clinicians and game developers, therefore easing the process of choosing the video games to be used for physical rehabilitation.

Methods

We analyzed the main features of SG design to obtain significant clinical outcomes when applied to physical rehabilitation of patients recovering from motor impairments resulting from stroke, multiple sclerosis, and cerebral palsy. We implemented a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) database-adjusted electronic search strategy for the PubMed, IEEE Xplore, and Cochrane databases.

Results

We screened 623 related papers from 2010-2021 and identified 12 that presented results compatible with our inclusion criteria. A total of 512 participants with stroke (8 studies, 417 participants), cerebral palsy (1 study, 8 participants), and multiple sclerosis (2 studies, 46 participants) were included; 1 study targeting the elderly (41 participants) was also included. All studies assessed motor, sensory, and functional functions, while some also measured general health outcomes. Interventions with games were used for upper-limb motor rehabilitation. Of the 12 studies, 8 presented significant improvements in at least one clinical measurement, of which 6 presented games from the casual GG, 1 combined the casual, simulation, and exergaming GGs, and 2 combined the sports and simulation GGs.

Conclusions

Of the possible combinations of game design features (GG, GN, and GDS) described, custom-made casual games that resort to the first-person perspective, do not feature a visible player character, are played in single-player mode, and use nonimmersive virtual reality attain the best results in terms of positive clinical outcomes. In addition, the use of custom-made games versus commercial off-the-shelf games tends to give better clinical results, although the latter are perceived as more motivating and engaging.

Influence of the visuo-proprioceptive illusion of movement and motor imagery of the wrist on EEG cortical excitability among healthy participants

INTRODUCTION

Motor Imagery (MI) is a powerful tool to stimulate sensorimotor brain areas and is currently used in motor rehabilitation after a stroke. The aim of our study was to evaluate whether an illusion of movement induced by visuo-proprioceptive immersion (VPI) including tendon vibration (TV) and Virtual moving hand (VR) combined with MI tasks could be more efficient than VPI alone or MI alone on cortical excitability assessed using Electroencephalography (EEG).

METHODS

We recorded EEG signals in 20 healthy participants in 3 different conditions: MI tasks involving their non-dominant wrist (MI condition); VPI condition; and VPI with MI tasks (combined condition). Each condition lasted 3 minutes, and was repeated 3 times in randomized order. Our main judgment criterion was the Event-Related De-synchronization (ERD) threshold in sensori-motor areas in each condition in the brain motor area.

RESULTS

The combined condition induced a greater change in the ERD percentage than the MI condition alone, but no significant difference was found between the combined and the VPI condition (p = 0.07) and between the VPI and MI condition (p = 0.20).

CONCLUSION

This study demonstrated the interest of using a visuo-proprioceptive immersion with MI rather than MI alone in order to increase excitability in motor areas of the brain. Further studies could test this hypothesis among patients with stroke to provide new perspectives for motor rehabilitation in this population.

Sequential motor learning transfers from real to virtual environment

Background

Skill acquisition of motor learning between virtual environments (VEs) and real environments (REs) may be related. Although studies have previously examined the transfer of motor learning in VEs and REs through the same tasks, only a small number of studies have focused on studying the transfer of motor learning in VEs and REs by using different tasks. Thus, detailed effects of the transfer of motor skills between VEs and REs remain controversial. Here, we investigated the transfer of sequential motor learning between VEs and REs conditions.

Methods

Twenty-seven healthy volunteers performed two types of sequential motor learning tasks; a visually cued button-press task in RE (RE task) and a virtual reaching task in VE (VE task). Participants were randomly assigned to two groups in the task order; the first group was RE task followed by VE task and the second group was VE task followed by RE task. Subsequently, the response time in RE task and VE task was compared between the two groups respectively.

Results

The results showed that the sequential reaching task in VEs was facilitated after the sequential finger task in REs.

Conclusions

These findings suggested that the sequential reaching task in VEs can be facilitated by a motor learning task comprising the same sequential finger task in REs, even when a different task is applied.

The Use of the Term Virtual Reality in Post-Stroke Rehabilitation: A Scoping Review and Commentary

Virtual reality (VR) offers many opportunities for post-stroke rehabilitation. However, "VR" can refer to several types of computer-based rehabilitation systems. Since these systems may impact the feasibility and the efficacy of VR interventions, consistent terminology is important. In this study, we aimed to optimize the terminology for VR-based post-stroke rehabilitation by assessing whether and how review papers on this topic defined VR and what types of mixed reality systems were discussed. In addition, this review can inspire the use of consistent terminology for other researchers working with VR. We assessed the use of the term VR in review papers on post-stroke rehabilitation extracted from Scopus, Web of Science and PubMed. We also developed a taxonomy distinguishing 16 mixed reality systems based on three factors: immersive versus semi-immersive displays, the way in which real and virtual information is mixed, and the main input device. 64% of the included review papers (N = 121) explicitly defined VR and 33% of them described different subtypes of VR, with immersive and non-immersive VR as the most common distinction. The most frequently discussed input devices were motion-capture cameras and handheld devices, while regular 2D monitors were the most frequently mentioned output devices. Our analysis revealed that reviews on post-stroke VR rehabilitation did not or only broadly defined "VR" and did not focus on a specific system. Since the efficacy and feasibility of rehabilitation may depend on the specific system, we propose a new data-driven taxonomy to distinguish different systems, which is expected to facilitate communication amongst researchers and clinicians working with virtual reality.

Virtual Reality Rehabilitation and Exergames—Physical and Psychological Impact on Fall Prevention among the Elderly—A Literature Review

The present review is aimed at the effectiveness of virtual reality (VR) and exergames in the prevention of falls among the elderly. Falls become a significant problem in the aging population and lead to psychological, social, and physical impairment. Prevention of falls is crucial to the well-being of the elderly population and is one of the challenges of contemporary rehabilitation. Recently, in view of the threat of the SARS-CoV-2 pandemic, contactless methods of rehabilitation, including telerehabilitation, appear as valuable rehabilitation tools. This review is based on the PRISMA guidelines and was carried out in five databases: PubMed, Medline, Web of Science, Scopus, and PEDro. Twenty-one randomized controlled trials, focused on the application of VR and exergames in the prevention of falls, were included. This review suggests that VR training in rehabilitation appears to be a promising complement to traditional techniques of physiotherapy to improve specific physical outcomes. VR and exergames could be considered as a complement of standard physiotherapy and its possible continuation at home for elderly. However, further high-quality studies, with carefully designed protocols and proper blinding, are needed.

Feasibility and effect of interactive telerehabilitation on balance in individuals with chronic stroke: a pilot study

Background

Stroke survivors need continuing exercise intervention to maintain functional status. This study assessed the feasibility and efficacy of an interactive telerehabilitation exergaming system to improve balance in individuals with chronic stroke, compared to conventional one-on-one rehabilitation.

Methods

In this prospective case–control pilot study, 30 Taiwanese individuals with chronic stroke were enrolled and randomly allocated to an experimental group and a control group. All participants received intervention 3 times per week for 4 weeks in the study hospital. The experiment group underwent telerehabilitation using a Kinect camera-based interactive telerehabilitation system in an independent room to simulate home environment. In contrast, the control group received conventional one-on-one physiotherapy in a dedicated rehabilitation area. The effectiveness of interactive telerehabilitation in improving balance in stroke survivors was evaluated by comparing outcomes between the two groups. The primary outcome was Berg Balance Scale (BBS) scores. Secondary outcomes were performance of the Timed Up and Go (TUG) test, Modified Falls Efficacy Scale, Motricity Index, and Functional Ambulation Category.

Results

Comparison of outcomes between experimental and control groups revealed no significant differences between groups at baseline and post-intervention for all outcome measures. However, BBS scores improved significantly in both groups (control group: p = 0.01, effect size = 0.49; experimental group: p = 0.01, effect size = 0.70). Completion times of TUG tests also improved significantly in the experimental group (p = 0.005, effect size = 0.70).

Conclusion

The Kinect camera-based interactive telerehabilitation system demonstrates superior or equal efficacy compared to conventional one-on-one physiotherapy for improving balance in individuals with chronic stroke.

Trial registration ClinicalTrials.gov. NCT03698357. Registered October 4, 2018, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00866-8.

Telemedicine and Virtual Reality at Time of COVID-19 Pandemic: An Overview for Future Perspectives in Neurorehabilitation

In catastrophic situations such as pandemics, patients' healthcare including admissions to hospitals and emergency services are challenged by the risk of infection and by limitations of healthcare resources. In such a setting, the use of telemedicine interventions has become extremely important. New technologies have proved helpful in pandemics as a solution to improve the quality of life in vulnerable patients such as persons with neurological diseases. Moreover, telemedicine interventions provide at-home solutions allowing clinicians to telemonitor and assess patients remotely, thus minimizing risk of infection. After a review of different studies using telemedicine in neurological patients, we propose a telemedicine process flow for healthcare of subjects with chronic neurological disease to respond to the new challenges for delivering quality healthcare during the transformation of public and private healthcare organizations around the world forced by COVID-19 pandemic contingency. This telemedicine process flow represents a replacement for in-person treatment and thereby the provision equitable access to the care of vulnerable people. It is conceptualized as comprehensive service including (1) teleassistance with patient counseling and medical treatment, (2) telemonitoring of patients' health conditions and any changes over time, as well as (3) telerehabilitation, i.e., interventions to assess and promote body functions, activities, and consecutively participation. The hereby proposed telemedicine process flow could be adopted on a large scale to improve the public health response during healthcare crises like the COVID-19 pandemic but could equally promote equitable health care independent of people's mobility or location with respect to the specialized health care center.

Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy

More innovative technologies are used worldwide in patient's rehabilitation after stroke, as it represents a significant cause of disability. The majority of the studies use a single type of therapy in therapeutic protocols. We aimed to identify if the association of virtual reality (VR) therapy and mirror therapy (MT) exercises have better outcomes in lower extremity rehabilitation in post-stroke patients compared to standard physiotherapy. Fifty-nine inpatients from 76 initially identified were included in the research. One experimental group (n = 31) received VR therapy and MT, while the control group (n = 28) received standard physiotherapy. Each group performed seventy minutes of therapy per day for ten days. Statistical analysis was performed with nonparametric tests. Wilcoxon Signed-Rank test showed that both groups registered significant differences between pre-and post-therapy clinical status for the range of motion and muscle strength (p < 0.001 and Cohen's d between 0.324 and 0.645). Motor Fugl Meyer Lower Extremity Assessment also suggested significant differences pre-and post-therapy for both groups (p < 0.05 and Cohen's d 0.254 for the control group and 0.685 for the experimental group). Mann-Whitney results suggested that VR and MT as a therapeutic intervention have better outcomes than standard physiotherapy in range of motion (p < 0.05, Cohen's d 0.693), muscle strength (p < 0.05, Cohen's d 0.924), lower extremity functionality (p < 0.05, Cohen's d 0.984) and postural balance (p < 0.05, Cohen's d 0.936). Our research suggests that VR therapy associated with MT may successfully substitute classic physiotherapy in lower extremity rehabilitation after stroke.

Effect of Virtual Reality Gait Training on Participation in Survivors of Subacute Stroke: A Randomized Controlled Trial

OBJECTIVE

After stroke, people experience difficulties with walking that lead to restrictions in participation in daily life. The purpose of this study was to examine the effect of virtual reality gait training (VRT) compared to non-virtual reality gait training (non-VRT) on participation in community-living people after stroke.

METHODS

In this assessor-blinded, randomized controlled trial with 2 parallel groups, people were included between 2 weeks and 6 months after stroke and randomly assigned to the VRT group or non-VRT group. Participants assigned to the VRT group received training on the Gait Real-time Analysis Interactive Lab (GRAIL), and participants assigned to the non-VRT group received treadmill training and functional gait exercises without virtual reality. Both training interventions consisted of 12 30-minute sessions during 6 weeks. The primary outcome was participation measured with the restrictions subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P) 3 months postintervention. Secondary outcomes included subjective physical functioning, functional mobility, walking ability, dynamic balance, walking activity, fatigue, anxiety and depression, falls efficacy, and quality of life.

RESULTS

Twenty-eight participants were randomly assigned to the VRT group and 27 to the non-VRT group, of whom 25 and 22 attended 75% or more of the training sessions, respectively. No significant differences between the groups were found over time for the USER-P restrictions subscale (1.23; 95% CI = -0.76 to 3.23) or secondary outcome measures. Patients' experiences with VRT were positive, and no serious adverse events were related to the interventions.

CONCLUSIONS

The effect of VRT was not statistically different from non-VRT in improving participation in community-living people after stroke.

IMPACT

Although outcomes were not statistically different, treadmill-based VRT was a safe and well-tolerated intervention that was positively rated by people after stroke. VR training might, therefore, be a valuable addition to stroke rehabilitation.

LAY SUMMARY

VRT is feasible and was positively experienced by people after stroke. However, VRT was not more effective than non-VRT for improving walking ability and participation after stroke.

Using Virtual Reality as a Tool in the Rehabilitation of Movement Abnormalities in Schizophrenia

Movement abnormalities are prevalent across all stages of schizophrenia contributing to poor social functioning and reduced quality of life. To date, treatments are scarce, often involving pharmacological agents, but none have been shown to improve movement abnormalities effectively. Virtual reality (VR) is a tool used to simulate virtual environments where behavioral performance can be quantified safely across different tasks while exerting control over stimulus delivery, feedback and measurement in real time. Sensory information is transmitted via a head mounted display allowing users to directly interact with virtual objects and bodies using gestures and body movements in the real world to perform different actions, permitting a sense of immersion in the simulated virtual environment. Although, VR has been widely used for successful motor rehabilitation in a variety of different neurological domains, none have been exploited for motor rehabilitation in schizophrenia. The objectives of this article are to review movement abnormalities specific to schizophrenia, and how VR can be utilized to restore and improve motor functioning in patients with schizophrenia. Constructing VR-mediated motor-cognitive interventions that can help in retaining and transferring the learned outcomes to real life are also discussed.

Influence of virtual reality visual feedback on the illusion of movement induced by tendon vibration of wrist in healthy participants

Introduction

Illusion of movement induced by tendon vibration is an effective approach for motor and sensory rehabilitation in case of neurological impairments. The aim of our study was to investigate which modality of visual feedback in Virtual Reality (VR) associated with tendon vibration of the wrist could induce the best illusion of movement.

Methods

We included 30 healthy participants in the experiment. Tendon vibration inducing illusion of movement (wrist extension, 100Hz) was applied on their wrist during 3 VR visual conditions (10 times each): a moving virtual hand corresponding to the movement that the participants could feel during the tendon vibration (Moving condition), a static virtual hand (Static condition), or no virtual hand at all (Hidden condition). After each trial, the participants had to quantify the intensity of the illusory movement on a Likert scale, the subjective degree of extension of their wrist and afterwards they answered a questionnaire.

Results

There was a significant difference between the 3 visual feedback conditions concerning the Likert scale ranking and the degree of wrist’s extension (p<0.001). The Moving condition induced a higher intensity of illusion of movement and a higher sensation of wrist’s extension than the Hidden condition (p<0.001 and p<0.001 respectively) than that of the Static condition (p<0.001 and p<0.001 respectively). The Hidden condition also induced a higher intensity of illusion of movement and a higher sensation of wrist’s extension than the Static condition (p<0.01 and p<0.01 respectively). The preferred condition to facilitate movement’s illusion was the Moving condition (63.3%).

Conclusions

This study demonstrated the importance of carefully selecting a visual feedback to improve the illusion of movement induced by tendon vibration, and the increase of illusion by adding VR visual cues congruent to the illusion of movement. Further work will consist in testing the same hypothesis with stroke patients.

Improving performance in motor imagery BCI-based control applications via virtually embodied feedback

OBJECTIVE

Brain-computer interfaces (BCIs) based on motor imagery (MI) are commonly used for control applications. However, these applications require strong and discriminant neural patterns for which extensive experience in MI may be necessary. Inspired by the field of rehabilitation where embodiment is a key element for improving cortical activity, our study proposes a novel control scheme in which virtually embodiable feedback is provided during control to enhance performance.

METHODS

Subjects underwent two immersive virtual reality control scenarios in which they controlled the two-dimensional movement of a device using electroencephalography (EEG). The two scenarios only differ on whether embodiable feedback, which mirrors the movement of the classified intention, is provided. After undergoing each scenario, subjects also answered a questionnaire in which they rated how immersive the scenario and embodiable the feedback were.

RESULTS

Subjects exhibited higher control performance, greater discriminability in brain activity patterns, and enhanced cortical activation when using our control scheme compared to the standard control scheme in which embodiable feedback is absent. Moreover, the self-rated embodiment and presence scores showed significantly positive linear relationships with performance.

SIGNIFICANCE

The findings in our study provide evidence that providing embodiable feedback as guidance on how intention is classified may be effective for control applications by inducing enhanced neural activity and patterns with greater discriminability. By applying embodiable feedback to immersive virtual reality, our study also serves as another instance in which virtual reality is shown to be a promising tool for improving MI.

Designing a Virtual Reality Game for Promoting Empathy Toward Patients With Chronic Pain: Feasibility and Usability Study

Background

Many researchers have been evaluating how digital media may impact the emotional and perspective taking aspects of empathy in both clinical and nonclinical settings. Despite the growing interest in using virtual reality (VR) and VR games to motivate empathy, few studies have focused on empathy for people who live with chronic pain.

Objective

Chronic pain affects, by conservative estimates, 1 in 5 people in industrialized countries. Despite this prevalence, public awareness of chronic pain was remarkably low until the recent opioid crisis; as a result, stigma remains a problem frequently faced by people who live with this condition. To address this, the VR game AS IF was developed to increase nonpatients’ empathy toward the growing number of people who live with long-term chronic pain. On the basis of our prior work, we overhauled our approach, designed and built a VR prototype and evaluated it, and offered design suggestions for future research.

Methods

We introduced the design features of the VR game AS IF and described the study we devised to evaluate its effectiveness. We adopted a mixed methods approach and compared the empathy-related outcomes in both pre- and posttesting. A total of 19 participants were recruited.

Results

The findings of this study suggest that the VR game was effective in improving implicit and explicit empathy as well as its emotional and perspective taking aspects. More specifically, for the Empathy Scale, the total pretest scores (mean 47.33, SD 4.24) and posttest scores (mean 59.22, SD 4.33) did not reach statistical significance (P=.08). However, we did find differences in the subscales. The kindness subscale showed a statistically significant increase in the posttest score (mean 15.61, SD 2.85) compared with the pretest score (mean 17.06, SD 2.65;P=.001). For the Willingness to Help Scale, a significant increase was observed from a t test analysis (P<.001) of scores before (mean 7.17, SD 2.28) and after (mean 8.33, SD 2.03) the gameplay. The effect size for this analysis was large (d=−1.063).

Conclusions

The contributions of this research are as follows: AS IF provides a promising approach for designing VR games to motivate people’s empathy toward patients with chronic pain, the study evaluates the potential effectiveness of such a VR approach, and the general design suggestions devised from this study could shed light on future VR game systems.

Influence on the user's emotional state of the graphic complexity level in virtual therapies based on a robot-assisted neuro-rehabilitation platform

BACKGROUND

In recent years, a remarkable trend in neurorehabilitation is the combination of conventional methods and emerging technologies, such as robotic platforms with virtual reality (VR), Serious Games (SG) and other types of sophisticated graphic interfaces. The aim of the present study is to evaluate the influence on the user's mental workload of the degree of graphic detail present in this kind of environments, comparing the experience of subjects working with two graphical environments with the same physical load but radically different graphic detail levels.

METHODS

The same therapy is performed by 52 healthy subjects in two totally different graphic environments, one rich in details and visual stimuli, and its schematic version focusing just in the target graphic elements. Autonomic Nervous System (ANS) activity, related to emotional state, is analyzed through the capture and processing of associated physiological signals. The SAM test is used to assess the subjective perception of the participants in order to establish a relationship with the calculated physiological parameters.

RESULTS

Indexes calculated from the ANS physiological signals show significant differences between the basal state and those corresponding to the performance of the therapies but do not allow discriminating between the effects of performing a therapy based on an environment rich in stimuli and an austere one. In the case of subjective perceptions, based on the results of the SAM test, the subjects perceive significant differences between the basal stage and the therapies, and also between each of the two graphic environments.

CONCLUSIONS

Users reflected that a graphic environment rich in detail was more pleasant and attractive than a schematic one. However, this is not reflected in values obtained from their physiological activity, which suggests that more research is needed about the online inference of the emotional state of the subject from the record of his physiological activity.

Effect of Virtual Reality on Balance in Individuals With Parkinson Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Virtual reality (VR) is a frequently used intervention for the rehabilitation of individuals with neurological disorders.

PURPOSE

The aims of this review were to identify the short-term effect of VR on balance and to compare it with the effect of active interventions in individuals with Parkinson disease (PD).

DATA SOURCES

Searches for relevant articles available in English were conducted using the MEDLINE (via PubMed), EMBASE, CENTRAL, CINAHL, PsycINFO, and Physiotherapy Evidence Database databases from inception until March 2019.

STUDY SELECTION

All randomized controlled trials comparing the effect of training with VR and the effect of training without VR on balance in individuals with PD were included.

DATA EXTRACTION

Two authors independently extracted data, assessed the methodological quality, and evaluated the evidence quality of the studies.

DATA SYNTHESIS

Fourteen randomized controlled trials including 574 individuals were eligible for qualitative analyses, and 12 of the studies involving 481 individuals were identified as being eligible for meta-analyses. Compared with active interventions, the use of VR improved the Berg Balance Scale score (mean difference = 1.23; 95% CI = 0.15 to 2.31; I2 = 56%). The Dynamic Gait Index and Functional Gait Assessment results were also significant after the sensitivity analyses (mean difference = 0.69; 95% CI = 0.12 to 1.26; I2 = 0%). Both provided moderate statistical evidence. However, the Timed "Up & Go" Test and the Activities-Specific Balance Confidence Scale did not differ significantly.

LIMITATIONS

Publication bias and diversity in the interventions were the main limitations.

CONCLUSIONS

Existing moderate evidence of the effectiveness of VR with the Berg Balance Scale, Dynamic Gait Index, and Functional Gait Assessment for individuals with PD was promising. Although the differences did not reach the clinically important change threshold, VR was comparable to active interventions and could be considered an adjuvant therapy for balance rehabilitation in individuals with PD.

Immersive Virtual Reality in Stroke Patients as a New Approach for Reducing Postural Disabilities and Falls Risk: A Case Series

Stroke is a neurologic disorder considered the first cause of disability worldwide due to motor, cognitive, and sensorial sequels. Balance dysfunctions in stroke survivors increase the risk of falls and physiotherapeutic rehabilitation is essential to reduce it. Virtual reality (VR) seems to be an alternative to conventional physiotherapy (CT), providing virtual environments and multisensorial inputs to train balance in stroke patients. The aim of this study was to assess if immersive VR treatment is more effective than CT to improve balance after stroke. This study got the approval from the Ethics Committee of the University of Almeria. Three chronic ischemic stroke patients were selected. One patient who received 25 sessions of immersive VR intervention for two months was compared with another patient who received equivalent CT and a third patient with no intervention. Balance, gait, risk of falling, and vestibular and visual implications in the equilibrium were assessed. After the interventions, the two patients receiving any of the treatments showed an improvement in balance compared to the untreated patient. In comparison to CT, our results suggest a higher effect of immersive VR in the improvement of balance and a reduction of falls risk due to the active upright work during the VR intervention.

The Potential of Virtual Reality for Inducing Neuroplasticity in Children with Amblyopia

In recent years, virtual reality (VR) has emerged as a new safe and effective tool for neurorehabilitation of different childhood and adulthood conditions. VR-based therapies can induce cortical reorganization and promote the activation of different neuronal connections over a wide range of ages, leading to contrasted improvements in motor and functional skills. The use of VR for the visual rehabilitation in amblyopia has been investigated in the last years, with the potential of using serious games combining perceptual learning and dichoptic stimulation. This combination of technologies allows the clinician to measure, treat, and control changes in interocular suppression, which is one of the factors leading to cortical alterations in amblyopia. Several clinical researches on this issue have been conducted, showing the potential of promoting visual acuity, contrast sensitivity, and stereopsis improvement. Indeed, several systems have been evaluated for amblyopia treatment including the use of different commercially available types of head mounted displays (HMDs). These HMDs are mostly well tolerated by patients during short exposures and do not cause significant long-term side effects, although their use has been occasionally associated with some visual discomfort and other complications in certain types of subjects. More studies are needed to confirm these promising therapies in controlled randomized clinical trials, with special emphasis on the definition of the most adequate planning for obtaining an effective recovery of the visual and binocular function.

Technological Advancements in Cerebral Palsy Rehabilitation

Smaller, smarter, more portable rehabilitation technology has the potential to improve the ability of individuals with cerebral palsy to perform activities and increase participation. Robotics and virtual reality may improve movement by maximizing exercise dose, providing feedback, and motivating users. Augmentative and alternative communication technology is facilitating communication. Robots can help with self-care and provide encouragement and instruction in rehabilitation programs. Mobile applications can provide education and resources. Conducting high-quality research to validate technological advances in our field has been a major focus of researchers and advocacy groups.

Learning and transfer of complex motor skills in virtual reality: a perspective review

The development of more effective rehabilitative interventions requires a better understanding of how humans learn and transfer motor skills in real-world contexts. Presently, clinicians design interventions to promote skill learning by relying on evidence from experimental paradigms involving simple tasks, such as reaching for a target. While these tasks facilitate stringent hypothesis testing in laboratory settings, the results may not shed light on performance of more complex real-world skills. In this perspective, we argue that virtual environments (VEs) are flexible, novel platforms to evaluate learning and transfer of complex skills without sacrificing experimental control. Specifically, VEs use models of real-life tasks that afford controlled experimental manipulations to measure and guide behavior with a precision that exceeds the capabilities of physical environments. This paper reviews recent insights from VE paradigms on motor learning into two pressing challenges in rehabilitation research: 1) Which training strategies in VEs promote complex skill learning? and 2) How can transfer of learning from virtual to real environments be enhanced? Defining complex skills by having nested redundancies, we outline findings on the role of movement variability in complex skill acquisition and discuss how VEs can provide novel forms of guidance to enhance learning. We review the evidence for skill transfer from virtual to real environments in typically developing and neurologically-impaired populations with a view to understanding how differences in sensory-motor information may influence learning strategies. We provide actionable suggestions for practicing clinicians and outline broad areas where more research is required. Finally, we conclude that VEs present distinctive experimental platforms to understand complex skill learning that should enable transfer from therapeutic practice to the real world.

What is the impact of user affect on motor learning in virtual environments after stroke? A scoping review

PURPOSE

The purported affective impact of virtual reality (VR) and active video gaming (AVG) systems is a key marketing strategy underlying their use in stroke rehabilitation, yet little is known as to how affective constructs are measured or linked to intervention outcomes. The purpose of this scoping review is to 1) explore how motivation, enjoyment, engagement, immersion and presence are measured or described in VR/AVG interventions for patients with stroke; 2) identify directional relationships between these constructs; and 3) evaluate their impact on motor learning outcomes.

METHODS

A literature search was undertaken of VR/AVG interventional studies for adults post-stroke published in Medline, PEDro and CINAHL databases between 2007 and 2017. Following screening, reviewers used an iterative charting framework to extract data about construct measurement and description. A numerical and thematic analytical approach adhered to established scoping review guidelines.

RESULTS

One hundred fifty-five studies were included in the review. Although the majority (89%; N = 138) of studies described at least one of the five constructs within their text, construct measurement took place in only 32% (N = 50) of studies. The most frequently described construct was motivation (79%, N = 123) while the most frequently measured construct was enjoyment (27%, N = 42). A summative content analysis of the 50 studies in which a construct was measured revealed that constructs were described either as a rationale for the use of VR/AVGs in rehabilitation (76%, N = 38) or as an explanation for intervention results (56%, N = 29). 38 (76%) of the studies proposed relational links between two or more constructs and/or between any construct and motor learning. No study used statistical analyses to examine these links.

CONCLUSIONS

Results indicate a clear discrepancy between the theoretical importance of affective constructs within VR/AVG interventions and actual construct measurement. Standardized terminology and outcome measures are required to better understand how enjoyment, engagement, motivation, immersion and presence contribute individually or in interaction to VR/AVG intervention effectiveness.