Virtual rehabilitation of upper extremity function and independence for stoke: a meta-analysis

The efficacy of virtual reality for upper limb rehabilitation in stroke patients: a systematic review and meta-analysis

BACKGROUND

Stroke frequently gives rise to incapacitating motor impairments in the upper limb. Virtual reality (VR) rehabilitation has exhibited potential for augmenting upper extremity recovery; nonetheless, the optimal techniques for such interventions remain a topic of uncertainty. The present systematic review and meta-analysis were undertaken to comprehensively compare VR-based rehabilitation with conventional occupational therapy across a spectrum of immersion levels and outcome domains.

METHODS

A systematic search was conducted in PubMed, IEEE, Scopus, Web of Science, and PsycNET databases to identify randomized controlled trials about upper limb rehabilitation in stroke patients utilizing VR interventions. The search encompassed studies published in the English language up to March 2023. The identified studies were stratified into different categories based on the degree of immersion employed: non-immersive, semi-immersive, and fully-immersive settings. Subsequent meta-analyses were executed to assess the impact of VR interventions on various outcome measures.

RESULTS

Of the 11,834 studies screened, 55 studies with 2142 patients met the predefined inclusion criteria. VR conferred benefits over conventional therapy for upper limb motor function, functional independence, Quality of life, Spasticity, and dexterity. Fully immersive VR showed the greatest gains in gross motor function, while non-immersive approaches enhanced fine dexterity. Interventions exceeding six weeks elicited superior results, and initiating VR within six months post-stroke optimized outcomes.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that adjunctive VR-based rehabilitation enhances upper limb motor recovery across multiple functional domains compared to conventional occupational therapy alone after stroke. Optimal paradigms likely integrate VR's immersive capacity with conventional techniques.

TRIAL REGISTRATION

This systematic review and meta-analysis retrospectively registered in the OSF registry under the identifier [ https://doi.org/10.17605/OSF.IO/YK2RJ ].

Artificial intelligence-driven virtual rehabilitation for people living in the community: A scoping review

Virtual Rehabilitation (VRehab) is a promising approach to improving the physical and mental functioning of patients living in the community. The use of VRehab technology results in the generation of multi-modal datasets collected through various devices. This presents opportunities for the development of Artificial Intelligence (AI) techniques in VRehab, namely the measurement, detection, and prediction of various patients' health outcomes. The objective of this scoping review was to explore the applications and effectiveness of incorporating AI into home-based VRehab programs. PubMed/MEDLINE, Embase, IEEE Xplore, Web of Science databases, and Google Scholar were searched from inception until June 2023 for studies that applied AI for the delivery of VRehab programs to the homes of adult patients. After screening 2172 unique titles and abstracts and 51 full-text studies, 13 studies were included in the review. A variety of AI algorithms were applied to analyze data collected from various sensors and make inferences about patients' health outcomes, most involving evaluating patients' exercise quality and providing feedback to patients. The AI algorithms used in the studies were mostly fuzzy rule-based methods, template matching, and deep neural networks. Despite the growing body of literature on the use of AI in VRehab, very few studies have examined its use in patients' homes. Current research suggests that integrating AI with home-based VRehab can lead to improved rehabilitation outcomes for patients. However, further research is required to fully assess the effectiveness of various forms of AI-driven home-based VRehab, taking into account its unique challenges and using standardized metrics.

Effects of Virtual Reality on the Limb Motor Function, Balance, Gait, and Daily Function of Patients with Stroke: Systematic Review

Background and Objectives: This systematic review aimed to clarify the effectiveness of virtual reality rehabilitation on physical outcomes for people with stroke. Materials and Methods: Articles were searched through PubMed, EMBASE, the Cochrane Library, the Physiotherapy Evidence Database, CINAHL, Web of Science, and ProQuest Dissertations and Theses, from inception to 30 April 2022. Methodological quality was scored using the Assessing the Methodological Quality of Systematic Reviews 2 tool. Each systematic review for the outcome of interest was assessed by two independent reviewers using the Grading of Recommendations Assessment, Development, and Evaluation system. Results: Twenty-six articles were selected. These studies evaluated the effectiveness of virtual reality on limb motor function, balance, gait, and daily function in patients with stroke. The findings suggested a beneficial effect of virtual reality; there was a "very low" to "moderate" quality of evidence for improved limb extremity function, balance, and daily function, and a "very low" to "moderate" quality of evidence for improved gait. Conclusions: Despite widespread interest in the use of virtual reality rehabilitation, high-quality evidence for its routine use in stroke treatment is lacking. Further research is needed to determine the treatment modality, duration, and long-term effects of virtual reality on stroke populations.

Survey of Movement Reproduction in Immersive Virtual Rehabilitation

Virtual reality (VR) has emerged as a powerful tool for rehabilitation. Many effective VR applications have been developed to support motor rehabilitation of people affected by motor issues. Movement reproduction, which transfers users' movements from the physical world to the virtual environment, is commonly used in VR rehabilitation applications. Three major components are required for movement reproduction in VR: (1) movement input, (2) movement representation, and (3) movement modulation. Until now, movement reproduction in virtual rehabilitation has not yet been systematically studied. This article aims to provide a state-of-the-art review on this subject by focusing on existing literature on immersive motor rehabilitation using VR. In this review, we provided in-depth discussions on the rehabilitation goals and outcomes, technology issues behind virtual rehabilitation, and user experience regarding movement reproduction. Similarly, we present good practices and highlight challenges and opportunities that can form constructive suggestions for the design and development of fit-for-purpose VR rehabilitation applications and can help frame future research directions for this emerging area that combines VR and health.

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

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

PREP Plus combined postrehabilitation programme to support upper limb recovery in community-dwelling stroke survivors: protocol for a mixed-methods, cluster-assigned feasibility study

INTRODUCTION

Poor recovery of the upper limb following a stroke has been recognised as a significant problem in the UK. Although there is good evidence that early, intense rehabilitation can lead to upper limb recovery, often this is not maintained, with less than 50% of people regaining the ability to use their upper limb for independent function at 6 months. Upper limb recovery potential is reported for many years poststroke, yet current long-term provision is insufficient.

METHODS AND ANALYSIS

60 participants will be recruited into this feasibility study, with 30 allocated to a Post Rehabilitation Enablement Programme (PREP) alone and 30 allocated to a combined programme, PREP Plus, consisting of PREP and the Graded Repetitive Arm Supplementary Programme (GRASP). We will aim to complete four iterative waves. Within each wave, the intervention design will be refined, based on participant feedback. Within each wave, there will be one cluster unit (one intervention group ;PREP Plus) and one control group ;PREP alone)). A total of five PREP sites within Northern Ireland Health and Social Care Trusts will be used for this study. PREP Plus will have a home exercise component along with exercises logs and a behaviour contract. Qualitative and quantitative measures will evaluate the acceptability and feasibility to determine how feasible it is to embed the intervention into practice, as well as to determine the feasibility of a larger, mixed-methods, randomised controlled trial to assess intervention efficacy. Clinical endpoints will also be explored.

ETHICS AND DISSEMINATION

This study has been approved by the Health and Social Care Research Ethics Committee A, IRAS project ID (278620). Participants will provide informed consent prior to participating in the study. Information outlining the purpose of the study, what data will be collected and how the data will be managed will be provided. Results will be published in peer-reviewed journals and any published data will be available on the university data repository. The project management group will advise on different avenues for dissemination to ensure it reaches appropriate audiences.

TRIAL REGISTRATION NUMBER

NCT05090163.

Validating the accuracy of a novel virtual reality platform for determining implant orientation in simulated primary total hip replacement

Introduction

Accurate acetabular cup and femoral stem component orientation are critical for optimising patient outcomes, reducing complications and increasing component longevity following total hip replacement (THR). This study aimed to determine the accuracy of a novel virtual reality (VR) platform in assessing component orientation in a simulated THR model.

Methods

The VR platform (HTC Vive Pro® system hardware) was compared against the validated Vicon® optical motion capture (MoCap) system. An acetabular cup and femoral stem were manually implanted across a range of orientations into pelvic and femur sawbones, respectively. Simultaneous readings of the acetabular cup operative anteversion (OA) and inclination (OI) and femoral stem alignment (FSA) and neck anteversion (FNA) were obtained from the VR and MoCap systems. Statistical analysis was performed using Pearson product-moment correlation coefficient (PPMCC) (Pearson’s r) and linear regression (R²).

Results

A total of 55 readings were obtained for the acetabular cup and 68 for the femoral stem model. The mean average differences in OA, OI, FSA and FNA between the systems were 3.44°, −0.01°, 0.01° and −0.04°, respectively. Strong positive correlations were demonstrated between both systems in OA, OI, FSA and FNA, with Pearson’s r = 0.92, 0.94, 0.99 and 0.99, and adjusted R² = 0.82, 0.9, 0.98 and 0.98, respectively.

Conclusion

The novel VR platform is highly accurate and reliable in determining both acetabular cup and femoral stem component orientations in simulated THR models. This adaptable and cost-effective digital tracking platform may be modified for use in a range of simulated surgical training and educational purposes, particularly in orthopaedic surgery.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

The Impact of Cognitive Function on Virtual Reality Intervention for Upper Extremity Rehabilitation of Patients With Subacute Stroke: Prospective Randomized Controlled Trial With 6-Month Follow-up

Background

Stroke is among the leading causes of long-term disability worldwide. Motor impairments after stroke not only impact the individuals quality of life but also lay substantial burdens on the society. Motor planning is a key component of cognitive function that impacts motor control. Hand movements such as grasping or reaching to grasp require the application of correct force and the coordination of multiple limb segments. Successful completion of hand motor task requires a certain degree of cognitive function to anticipate the requirement of the task. Cognitive function may thus be a confounding factor to rehabilitation outcomes.

Objective

This study aims to explore the impact of cognitive function on functional outcomes in people with subacute stroke after VR intervention.

Methods

Patients with stroke were first stratified into cognitively normal (CN) and cognitively impaired (CI), followed by allocation to the VR or control group (CG). Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Barthel Index (BI), and Instrumental Activities of Daily Living (IADL) were recorded at baseline, 3 weeks after the intervention, and 3 and 6 months after the intervention. The between-group and within-group differences were assessed by repeated-measures analysis of variance (ANOVA).

Results

The between-group comparison indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) scores improved significantly in both groups after the intervention. Repeated-measures ANOVA indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) were significantly different in each subgroup after the intervention. For BI score, the ANOVA results showed obvious interaction effects (treatment × time × cognitive effect, P=.04).

Conclusions

VR intervention was as effective as traditional conventional therapy in improving upper limb function regardless of the cognitive functional level. Patients with stroke with impaired cognitive function may gain more improvement in upper limb function and independency in performing activities of daily living after a VR-based intervention.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-IOC-15006064; https://tinyurl.com/4c9vkrrn

Rehabilitation of Upper Extremity by Telerehabilitation Combined With Exergames in Survivors of Chronic Stroke: Preliminary Findings From a Feasibility Clinical Trial

BACKGROUND

Exergames are increasingly being used among survivors of stroke with chronic upper extremity (UE) sequelae to continue exercising at home after discharge and maintain activity levels. The use of virtual reality exergames combined with a telerehabilitation app (VirTele) may be an interesting alternative to rehabilitate the UE sequelae in survivors of chronic stroke while allowing for ongoing monitoring with a clinician.

OBJECTIVE

This study aimed to determine the feasibility of using VirTele in survivors of chronic stroke at home and explore the impact of VirTele on UE motor function, quantity and quality of use, quality of life, and motivation in survivors of chronic stroke compared with conventional therapy.

METHODS

This study was a 2-arm feasibility clinical trial. Eligible participants were randomly allocated to an experimental group (receiving VirTele for 8 weeks) or a control group (receiving conventional therapy for 8 weeks). Feasibility was measured from the exergame and intervention logs completed by the clinician. Outcome measurements included the Fugl-Meyer Assessment-UE, Motor Activity Log-30, Stroke Impact Scale-16, and Treatment Self-Regulation Questionnaire-15, which were administered to both groups at four time points: time point 1 (T1; before starting the intervention), time point 2 (after the intervention), time point 3 (1 month after the intervention), and time point 4 (T4; 2 months after the intervention).

RESULTS

A total of 11 survivors of stroke were randomized and allocated to an experimental or a control group. At the onset of the COVID-19 pandemic, participants pursued the allocated treatment for 3 months instead of 8 weeks. VirTele intervention dose was captured in terms of time spent on exergames, frequency of use of exergames, total number of successful repetitions, and frequency of videoconference sessions. Technical issues included the loss of passwords, internet issues, updates of the system, and problems with the avatar. Overall, most survivors of stroke found the technology easy to use and useful, except for 9% (1/11) of participants. For the Fugl-Meyer Assessment-UE and Motor Activity Log-30, both groups exhibited an improvement in >50% of the participants, which was maintained over time (from time point 3 to T4). Regarding Stroke Impact Scale-16 scores, the control group reported improvement in activities of daily life (3/5, 60%), hand function (5/5, 100%), and mobility (2/5, 40%), whereas the experimental group reported varied and inconclusive results (from T1 to T4). For the Treatment Self-Regulation Questionnaire-15, 75% (3/4) of the experimental group demonstrated an increase in the autonomous motivation score (from T1 to time point 2), whereas, in the control group, this improvement was observed in only 9% (1/11) of participants.

CONCLUSIONS

The VirTele intervention constitutes another therapeutic alternative, in addition to conventional therapy, to deliver an intense personalized rehabilitation program for survivors of chronic stroke with UE sequelae.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/14629.

User-Centered Virtual Environment for Post-Stroke Motor Rehabilitation

The use of Virtual Reality in the rehabilitation of lost or diminished functions after a stroke has been shown to be an innovative means in motor recovery. However, there are still several design challenges to increment the efficiency of these systems. This paper presents the development and evaluation of a non-immersive 3D virtual environment for post-stroke rehabilitation of elbow flexion-extension movements, which considers the therapist as a direct user and the patient as a secondary user. The development of virtual environment was supported by the criteria of a team of specialists in physical and occupational therapy, following the philosophy of User-Centered Design through three iterations, and incorporating tasks based on the Activities of Daily Living of the Barthel scale. Tests were carried out with healthy users and a patient with a diagnosis of stroke, using the SUS test and a flow status questionnaire respectively. Average satisfaction of user group without diagnosis was 79.6 out of 100 points. On the other hand, according to mean values observed with the patient, dimensions of control sense (6.33) and positive emotional experience (6.66) reflect an "optimal" experience, which indicates an enjoyment of virtual tasks de-spite the effort made to fulfill them.

Overground Walking in a Fully Immersive Virtual Reality: A Comprehensive Study on the Effects on Full-Body Walking Biomechanics

Virtual reality (VR) is an emerging technology offering tremendous opportunities to aid gait rehabilitation. To this date, real walking with users immersed in virtual environments with head-mounted displays (HMDs) is either possible with treadmills or room-scale (overground) VR setups. Especially for the latter, there is a growing interest in applications for interactive gait training as they could allow for more self-paced and natural walking. This study investigated if walking in an overground VR environment has relevant effects on 3D gait biomechanics. A convenience sample of 21 healthy individuals underwent standard 3D gait analysis during four randomly assigned walking conditions: the real laboratory (RLab), a virtual laboratory resembling the real world (VRLab), a small version of the VRlab (VRLab-), and a version which is twice as long as the VRlab (VRLab+). To immerse the participants in the virtual environment we used a VR-HMD, which was operated wireless and calibrated in a way that the virtual labs would match the real-world. Walking speed and a single measure of gait kinematic variability (GaitSD) served as primary outcomes next to standard spatio-temporal parameters, their coefficients of variant (CV%), kinematics, and kinetics. Briefly described, participants demonstrated a slower walking pattern (-0.09 ± 0.06 m/s) and small accompanying kinematic and kinetic changes. Participants also showed a markedly increased gait variability in lower extremity gait kinematics and spatio-temporal parameters. No differences were found between walking in VRLab+ vs. VRLab-. Most of the kinematic and kinetic differences were too small to be regarded as relevant, but increased kinematic variability (+57%) along with increased percent double support time (+4%), and increased step width variability (+38%) indicate gait adaptions toward a more conservative or cautious gait due to instability induced by the VR environment. We suggest considering these effects in the design of VR-based overground training devices. Our study lays the foundation for upcoming developments in the field of VR-assisted gait rehabilitation as it describes how VR in overground walking scenarios impacts our gait pattern. This information is of high relevance when one wants to develop purposeful rehabilitation tools.

Effectiveness of virtual reality-based rehabilitation versus conventional therapy on upper limb motor function of chronic stroke patients: a systematic review and meta-analysis of randomized controlled trials

Objective: To systematically review the available randomized controlled trials in the literature concerning the application of virtual reality (VR) rehabilitation interventions compared to conventional physical therapy, in regaining the upper limb motor function among patients with chronic stroke. Methods: A systematic electronic database search was conducted for related studies published from inauguration and until June 25, 2020 in nine databases. Another new search was done on February 1, 2021 and no new studies were identified. Results: Six studies were included in the analysis. Significant improvement was seen following the VR therapy in patients with chronic stroke, compared to their scores prior to it (SMD = 0.28; 95% CI = 0.03-0.53; p = .03). There was neither heterogeneity (I² = 0% and P = .5) nor a risk of bias (P = .8) among the included studies. VR interventions produced a comparable effectiveness to that of the conventional rehabilitation, with no statistically significant difference (SMD = 0.15; 95% CI = -0.14-0.44; P = .3). There was neither heterogeneity (I² = 40% and P = .1) nor a risk of bias (P = .5) among the included studies. Conclusions: The upper limb motor function of patients with chronic stroke who underwent VR-based rehabilitative intervention showed significant improvement as compared to the pre-treatment state. Our analysis also revealed no superiority of VR interventions over conservative therapies; however, the difference observed did not accomplish statistical significance.

Movement-Related Cortical Potentials in Embodied Virtual Mirror Visual Feedback

Background: Mirror therapy is thought to drive interhemispheric communication, resulting in a balanced activation. We hypothesized that embodied virtual mirror visual feedback (VR-MVF) presented on a computer screen may produce a similar activation. In this proof-of-concept study, we investigated differences in movement-related cortical potentials (MRCPs) in the electroencephalogram (EEG) from different visual feedback of user movements in 1 stroke patient and 13 age-matched adults. Methods: A 60-year-old right-handed (Edinburgh score >95) male ischemic stroke [left paramedian pontine, National Institutes of Health Stroke Scale (NIHSS) = 6] patient and 13 age-matched right-handed (Edinburgh score >80) healthy adults (58 ± 9 years; six female) participated in the study. We recorded 16-electrode electroencephalogram (EEG), while participants performed planar center-out movements in two embodied visual feedback conditions: (i) direct (movements translated to the avatar's ipsilateral side) and (ii) mirror (movements translated to the avatar's contralateral side) with left (direct left/mirror left) or right (direct right/mirror right) arms. Results: As hypothesized, we observed more balanced MRCP hemispheric negativity in the mirror right compared to the direct right condition [statistically significant at the FC4 electrode; 99.9% CI, (0.81, 13)]. MRCPs in the stroke participant showed reduced lateralized negativity in the direct left (non-paretic) situation compared to healthy participants. Interestingly, the potentials were stronger in the mirror left (non-paretic) compared to direct left case, with significantly more bilateral negativity at FC3 [95% CI (0.758 13.2)] and C2 [95% CI (0.04 9.52)]. Conclusions: Embodied mirror visual feedback is likely to influence bilateral sensorimotor cortical subthreshold activity during movement preparation and execution observed in MRCPs in both healthy participants and a stroke patient.

Virtual Reality in Neurorehabilitation: An Umbrella Review of Meta-Analyses

Neurological disorders are a leading cause of death and disability worldwide. Can virtual reality (VR) based intervention, a novel technology-driven change of paradigm in rehabilitation, reduce impairments, activity limitations, and participation restrictions? This question is directly addressed here for the first time using an umbrella review that assessed the effectiveness and quality of evidence of VR interventions in the physical and cognitive rehabilitation of patients with stroke, traumatic brain injury and cerebral palsy, identified factors that can enhance rehabilitation outcomes and addressed safety concerns. Forty-one meta-analyses were included. The data synthesis found mostly low- or very low-quality evidence that supports the effectiveness of VR interventions. Only a limited number of comparisons were rated as having moderate and high quality of evidence, but overall, results highlight potential benefits of VR for improving the ambulation function of children with cerebral palsy, mobility, balance, upper limb function, and body structure/function and activity of people with stroke, and upper limb function of people with acquired brain injury. Customization of VR systems is one important factor linked with improved outcomes. Most studies do not address safety concerns, as only nine reviews reported adverse effects. The results provide critical recommendations for the design and implementation of future VR programs, trials and systematic reviews, including the need for high quality randomized controlled trials to test principles and mechanisms, in primary studies and in meta-analyses, in order to formulate evidence-based guidelines for designing VR-based rehabilitation interventions.

Virtual Reality Facilitates Engagement in Physical Therapy in the Pediatric CVICU

PURPOSE

The purpose of this report is to demonstrate the successful application of virtual reality to improve physical therapy in the pediatric cardiovascular intensive care unit. Early mobilization and cognitive stimulation improve morbidity of critically ill children. However, maintaining child engagement with these therapies can be challenging, especially during extended intensive care stays.

SUMMARY OF KEY POINTS

While virtual reality has been successfully used as an analgesic and anxiolytic in the cardiovascular intensive care unit, this report demonstrates its novel use as a tool to augment physical therapy for a child who had been debilitated after heart transplantation. Virtual reality encouraged the child to engage in physical therapy sessions, participate for greater durations, and directly address barriers to discharge.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

While further studies are needed to define best practice, this report demonstrates that virtual reality can be safely used for carefully selected and monitored children in critical care.

Boxing training in patients with stroke causes improvement of upper extremity, balance, and cognitive functions but should it be applied as virtual or real?

Background: Upper extremity hemiparesis is one of the most common post-stroke disabilities requiring rehabilitation. Objective: To compare the effects of virtual and real boxing training in addition to neurodevelopmental treatment on the upper extremity, balance, and cognitive functions in hemiparetic stroke patients. Methods: Forty hemiparetic stroke patients were assigned to either real boxing group-RBG (n=20) or virtual boxing group-VBG (n=20), for a total of 24 sessions (3 sessions/week for 8 weeks). The primary outcome was upper extremity motor ability (Wolf Motor Function Test-WMFT). The secondary outcomes were arm-hand dexterity (Manual Dexterity Test-MMDT), goal-oriented performance (Video Boxing Analysis-VBA), balance functions (Fullerton Advanced Balance Scale-FAB-T), and cognitive functions (Addenbrooke's Cognitive Examination-Revised-ACE-R). Results: There was small treatment effect on ACE-R, small-medium effect for WFMT and MMDT and large effect on bilateral punching time [VBA (Cohen's d- VBG=0.83; RBG=0.95)] and balance [FAB-T (Cohen's d - VBG=0.89; RBG=0.82)] after treatment in both groups. No significant differences were found for training effects between the groups for upper extremity functions [WMFT (p=0.799; Cohen's d=-0.07), MMDT-PT (p=0.327; Cohen's d=-0.10), MMDT-THTPT (p=0.779; Cohen's d=-0.17) and VBA bilateral punch number (p=0.068; Cohen's d=0.15)], balance functions [FAB-T (p=0.602; Cohen's d=-0.19)] and cognitive functions [ACE-R total (p=0.947, Cohen's d=0.09)]. Conclusion: The study showed that virtual and real boxing training methods, in addition to neurodevelopmental treatment, are effective in improving upper extremity, balance, and cognitive functions in patients with hemiparetic stroke. The training effects were higher on bilateral punching time and balance functions for both groups. There was no superiority of either approach.

Non-Immersive Virtual Reality for Rehabilitation of the Older People: A Systematic Review into Efficacy and Effectiveness

: Objective: the objective of this review is to analyze the advances in the field of rehabilitation through virtual reality, while taking into account non-immersive systems, as evidence have them shown to be highly accepted by older people, due to the lowest "cibersikness" symptomatology.

DATA SOURCES

a systematic review of the literature was conducted in June 2019. The data were collected from Cochrane, Embase, Scopus, and PubMed databases, analyzing manuscripts and articles of the last 10 years.

STUDY SELECTION

we only included randomized controlled trials written in English aimed to study the use of the virtual reality in rehabilitation. We selected 10 studies, which were characterized by clinical heterogeneity.

DATA EXTRACTION

quality evaluation was performed based on the Physioterapy Evidence Database (PEDro) scale, suggested for evidence based review of stroke rehabilitation. Of 10 studies considered, eight were randomized controlled trials and the PEDro score ranged from four to a maximum of nine.

DATA SYNTHESIS

VR (Virtual Reality) creates artificial environments with the possibility of a patient interaction. This kind of experience leads to the development of cognitive and motor abilities, which usually positively affect the emotional state of the patient, increasing collaboration and compliance. Some recent studies have suggested that rehabilitation treatment interventions might be useful and effective in treating motor and cognitive symptoms in different neurological disorders, including traumatic brain injury, multiple sclerosis, and progressive supranuclear palsy.

CONCLUSIONS

as it is shown by the numerous studies in the field, the application of VR has a positive impact on the rehabilitation of the most predominant geriatric syndromes. The level of realism of the virtual stimuli seems to have a crucial role in the training of cognitive abilities. Future research needs to improve study design by including larger samples, longitudinal designs, long term follow-ups, and different outcome measures, including functional and quality of life indexes, to better evaluate the clinical impact of this promising technology in healthy old subjects and in neurological patients.

Agreement Analysis between Vive and Vicon Systems to Monitor Lumbar Postural Changes

Immersive virtual reality has recently developed into a readily available system that allows for full-body tracking. Can this affordable system be used for component tracking to advance or replace expensive kinematic systems for motion analysis in the clinic? The aim of this study was to assess the accuracy of position and orientation measures from Vive wireless body trackers when compared to Vicon optoelectronic tracked markers attached to (1) a robot simulating trunk flexion and rotation by repeatedly moving to know locations, and (2) healthy adults playing virtual reality games necessitating significant trunk displacements. The comparison of both systems showed component tracking with Vive trackers is accurate within 0.68 ± 0.32 cm translationally and 1.64 ± 0.18° rotationally when compared with a three-dimensional motion capture system. No significant differences between Vive trackers and Vicon systems were found suggesting the Vive wireless sensors can be used to accurately track joint motion for clinical and research data.