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Rätz R, Conti F, Thaler I, Müri RM, Marchal-Crespo L. Enhancing stroke rehabilitation with whole-hand haptic rendering: development and clinical usability evaluation of a novel upper-limb rehabilitation device. J Neuroeng Rehabil 2024; 21:172. [PMID: 39334423 PMCID: PMC11437669 DOI: 10.1186/s12984-024-01439-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 08/05/2024] [Indexed: 09/30/2024] Open
Abstract
INTRODUCTION There is currently a lack of easy-to-use and effective robotic devices for upper-limb rehabilitation after stroke. Importantly, most current systems lack the provision of somatosensory information that is congruent with the virtual training task. This paper introduces a novel haptic robotic system designed for upper-limb rehabilitation, focusing on enhancing sensorimotor rehabilitation through comprehensive haptic rendering. METHODS We developed a novel haptic rehabilitation device with a unique combination of degrees of freedom that allows the virtual training of functional reach and grasp tasks, where we use a physics engine-based haptic rendering method to render whole-hand interactions between the patients' hands and virtual tangible objects. To evaluate the feasibility of our system, we performed a clinical mixed-method usability study with seven patients and seven therapists working in neurorehabilitation. We employed standardized questionnaires to gather quantitative data and performed semi-structured interviews with all participants to gain qualitative insights into the perceived usability and usefulness of our technological solution. RESULTS The device demonstrated ease of use and adaptability to various hand sizes without extensive setup. Therapists and patients reported high satisfaction levels, with the system facilitating engaging and meaningful rehabilitation exercises. Participants provided notably positive feedback, particularly emphasizing the system's available degrees of freedom and its haptic rendering capabilities. Therapists expressed confidence in the transferability of sensorimotor skills learned with our system to activities of daily living, although further investigation is needed to confirm this. CONCLUSION The novel haptic robotic system effectively supports upper-limb rehabilitation post-stroke, offering high-fidelity haptic feedback and engaging training tasks. Its clinical usability, combined with positive feedback from both therapists and patients, underscores its potential to enhance robotic neurorehabilitation.
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Affiliation(s)
- Raphael Rätz
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland.
| | | | - Irène Thaler
- Department of Neurology, University Neurorehabilitation, University Hospital Bern (Inselspital), University of Bern, Bern, Switzerland
| | - René M Müri
- Department of Neurology, University Neurorehabilitation, University Hospital Bern (Inselspital), University of Bern, Bern, Switzerland
| | - Laura Marchal-Crespo
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
- Department of Cognitive Robotics, Delft University of Technology, Delft, The Netherlands
- Department of Rehabilitation Medicine, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Flores-Cortes M, Guerra-Armas J, Pineda-Galan C, La Touche R, Luque-Suarez A. Sensorimotor Uncertainty of Immersive Virtual Reality Environments for People in Pain: Scoping Review. Brain Sci 2023; 13:1461. [PMID: 37891829 PMCID: PMC10604973 DOI: 10.3390/brainsci13101461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION Decision making and action execution both rely on sensory information, and their primary objective is to minimise uncertainty. Virtual reality (VR) introduces uncertainty due to the imprecision of perceptual information. The concept of "sensorimotor uncertainty" is a pivotal element in the interplay between perception and action within the VR environment. The role of immersive VR in the four stages of motor behaviour decision making in people with pain has been previously discussed. These four processing levels are the basis to understand the uncertainty that a patient experiences when using VR: sensory information, current state, transition rules, and the outcome obtained. METHODS This review examines the different types of uncertainty that a patient may experience when they are immersed in a virtual reality environment in a context of pain. Randomised clinical trials, a secondary analysis of randomised clinical trials, and pilot randomised clinical trials related to the scope of Sensorimotor Uncertainty in Immersive Virtual Reality were included after searching. RESULTS Fifty studies were included in this review. They were divided into four categories regarding the type of uncertainty the intervention created and the stage of the decision-making model. CONCLUSIONS Immersive virtual reality makes it possible to alter sensorimotor uncertainty, but studies of higher methodological quality are needed on this topic, as well as an exploration into the patient profile for pain management using immersive VR.
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Affiliation(s)
- Mar Flores-Cortes
- Faculty of Health Sciences, University of Malaga, 29071 Malaga, Spain
| | | | | | - Roy La Touche
- Instituto de Dolor Craneofacial y Neuromusculoesquelético (INDCRAN), 28008 Madrid, Spain
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28023 Madrid, Spain
- Motion in Brains Research Group, Institute of Neuroscience and Sciences of the Movement (INCIMOV), Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28023 Madrid, Spain
| | - Alejandro Luque-Suarez
- Faculty of Health Sciences, University of Malaga, 29071 Malaga, Spain
- Instituto de Investigacion Biomedica de Malaga (IBIMA), 29071 Malaga, Spain
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Wenk N, Penalver-Andres J, Buetler KA, Nef T, Müri RM, Marchal-Crespo L. Effect of immersive visualization technologies on cognitive load, motivation, usability, and embodiment. VIRTUAL REALITY 2023; 27:307-331. [PMID: 36915633 PMCID: PMC9998603 DOI: 10.1007/s10055-021-00565-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/22/2021] [Indexed: 05/09/2023]
Abstract
Virtual reality (VR) is a promising tool to promote motor (re)learning in healthy users and brain-injured patients. However, in current VR-based motor training, movements of the users performed in a three-dimensional space are usually visualized on computer screens, televisions, or projection systems, which lack depth cues (2D screen), and thus, display information using only monocular depth cues. The reduced depth cues and the visuospatial transformation from the movements performed in a three-dimensional space to their two-dimensional indirect visualization on the 2D screen may add cognitive load, reducing VR usability, especially in users suffering from cognitive impairments. These 2D screens might further reduce the learning outcomes if they limit users' motivation and embodiment, factors previously associated with better motor performance. The goal of this study was to evaluate the potential benefits of more immersive technologies using head-mounted displays (HMDs). As a first step towards potential clinical implementation, we ran an experiment with 20 healthy participants who simultaneously performed a 3D motor reaching and a cognitive counting task using: (1) (immersive) VR (IVR) HMD, (2) augmented reality (AR) HMD, and (3) computer screen (2D screen). In a previous analysis, we reported improved movement quality when movements were visualized with IVR than with a 2D screen. Here, we present results from the analysis of questionnaires to evaluate whether the visualization technology impacted users' cognitive load, motivation, technology usability, and embodiment. Reports on cognitive load did not differ across visualization technologies. However, IVR was more motivating and usable than AR and the 2D screen. Both IVR and AR rea ched higher embodiment level than the 2D screen. Our results support our previous finding that IVR HMDs seem to be more suitable than the common 2D screens employed in VR-based therapy when training 3D movements. For AR, it is still unknown whether the absence of benefit over the 2D screen is due to the visualization technology per se or to technical limitations specific to the device.
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Affiliation(s)
- N. Wenk
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - J. Penalver-Andres
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - K. A. Buetler
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - T. Nef
- Gerontechnology & Rehabilitation, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - R. M. Müri
- Gerontechnology & Rehabilitation, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
- Department of Neurology, University Neurorehabilitation, University Hospital Bern (Inselspital), University of Bern, Bern, Switzerland
| | - L. Marchal-Crespo
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
- Department of Cognitive Robotics, Delft University of Technology, Delft, The Netherlands
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Tanaka T, Hayashida K, Morioka S. Verbal Suggestion Modulates the Sense of Ownership and Heat Pain Threshold During the "Injured" Rubber Hand Illusion. Front Hum Neurosci 2022; 16:837496. [PMID: 35547193 PMCID: PMC9082029 DOI: 10.3389/fnhum.2022.837496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
The appearance of the self-body influences the feeling that one's body belongs to oneself, that is, a sense of ownership (SoO) and pain perception. This can be identified by measuring the SoO and pain thresholds after performing the rubber hand illusion (RHI) with an injured rubber hand. The generation of SoO is thought to be caused by multisensory integration of bottom-up factors (vision, proprioceptive, and touch), and by top-down factors, such as the context effect. The appearance is one of the context effects which may become more effective when used simultaneously with other context effects (e.g., verbal suggestion). However, in the RHI, when appearance and other context effects are used simultaneously, the effect is unclear. In this study, we attempted to identify the influence of verbal suggestion on the SoO and heat pain threshold (HPT). As a preliminary step, in Experiment 1, the "normal" rubber hand and "penetrated nail" as injured rubber hand were used to clarify the context effect with appearance alone during RHI (synchronous/asynchronous), which was conducted within-subjects. In Experiment 2, we only used the "penetrated nail" rubber hand to clarify the context effect with verbal suggestion and appearance during RHI. We randomly classified participants into two suggestion groups ("fear" and "no-fear"). The RHI (synchronous/asynchronous) was conducted for each group. In each experiment, the effect of each condition was assessed by subjective measures of SoO, such as questionnaire, and objective measures of SoO, such as proprioceptive drift and electrodermal activity. Following RHI in each condition, HPT was measured. The main finding was that, in the synchronous condition, the "penetrated nail" appearance with "fear" verbal suggestion modulated questionnaire and HPT, but not electrodermal activity. We conclude that the context-included multisensory integration affected the subjective factors because it contains a higher cognitive process by verbal suggestion.
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Affiliation(s)
- Tomoya Tanaka
- Department of Neurorehabilitation, Graduate School of Health Sciences, Kio University, Koryo, Japan
- Department of Rehabilitation, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Kazuki Hayashida
- Neurorehabilitation Research Center, Kio University, Koryo, Japan
| | - Shu Morioka
- Department of Neurorehabilitation, Graduate School of Health Sciences, Kio University, Koryo, Japan
- Neurorehabilitation Research Center, Kio University, Koryo, Japan
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Buetler KA, Penalver-Andres J, Özen Ö, Ferriroli L, Müri RM, Cazzoli D, Marchal-Crespo L. "Tricking the Brain" Using Immersive Virtual Reality: Modifying the Self-Perception Over Embodied Avatar Influences Motor Cortical Excitability and Action Initiation. Front Hum Neurosci 2022; 15:787487. [PMID: 35221950 PMCID: PMC8863605 DOI: 10.3389/fnhum.2021.787487] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/13/2021] [Indexed: 02/02/2023] Open
Abstract
To offer engaging neurorehabilitation training to neurologic patients, motor tasks are often visualized in virtual reality (VR). Recently introduced head-mounted displays (HMDs) allow to realistically mimic the body of the user from a first-person perspective (i.e., avatar) in a highly immersive VR environment. In this immersive environment, users may embody avatars with different body characteristics. Importantly, body characteristics impact how people perform actions. Therefore, alternating body perceptions using immersive VR may be a powerful tool to promote motor activity in neurologic patients. However, the ability of the brain to adapt motor commands based on a perceived modified reality has not yet been fully explored. To fill this gap, we "tricked the brain" using immersive VR and investigated if multisensory feedback modulating the physical properties of an embodied avatar influences motor brain networks and control. Ten healthy participants were immersed in a virtual environment using an HMD, where they saw an avatar from first-person perspective. We slowly transformed the surface of the avatar (i.e., the "skin material") from human to stone. We enforced this visual change by repetitively touching the real arm of the participant and the arm of the avatar with a (virtual) hammer, while progressively replacing the sound of the hammer against skin with stone hitting sound via loudspeaker. We applied single-pulse transcranial magnetic simulation (TMS) to evaluate changes in motor cortical excitability associated with the illusion. Further, to investigate if the "stone illusion" affected motor control, participants performed a reaching task with the human and stone avatar. Questionnaires assessed the subjectively reported strength of embodiment and illusion. Our results show that participants experienced the "stone arm illusion." Particularly, they rated their arm as heavier, colder, stiffer, and more insensitive when immersed with the stone than human avatar, without the illusion affecting their experienced feeling of body ownership. Further, the reported illusion strength was associated with enhanced motor cortical excitability and faster movement initiations, indicating that participants may have physically mirrored and compensated for the embodied body characteristics of the stone avatar. Together, immersive VR has the potential to influence motor brain networks by subtly modifying the perception of reality, opening new perspectives for the motor recovery of patients.
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Affiliation(s)
- Karin A. Buetler
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Joaquin Penalver-Andres
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
- Psychosomatic Medicine, Department of Neurology, University Hospital of Bern (Inselspital), Bern, Switzerland
| | - Özhan Özen
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Luca Ferriroli
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - René M. Müri
- Gerontechnology and Rehabilitation Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
- Department of Neurology, University Neurorehabilitation, University Hospital of Bern (Inselspital), University of Bern, Bern, Switzerland
| | - Dario Cazzoli
- Gerontechnology and Rehabilitation Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
- Department of Neurology, University Neurorehabilitation, University Hospital of Bern (Inselspital), University of Bern, Bern, Switzerland
- Neurocenter, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Laura Marchal-Crespo
- Motor Learning and Neurorehabilitation Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
- Department of Cognitive Robotics, Delft University of Technology, Delft, Netherlands
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Wenk N, Jordi MV, Buetler KA, Marchal-Crespo L. Hiding Assistive Robots During Training in Immersive VR Does not Affect Users' Motivation, Presence, Embodiment, Performance, nor Visual Attention. IEEE Trans Neural Syst Rehabil Eng 2022; 30:390-399. [PMID: 35085087 DOI: 10.1109/tnsre.2022.3147260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Combining immersive virtual reality (VR) using head-mounted displays (HMDs) with assisting robotic devices might be a promising procedure to enhance neurorehabilitation. However, it is still an open question how immersive virtual environments (VE) should be designed when interacting with rehabilitation robots. In conventional training, the robot is usually not visually represented in the VE, resulting in a visuo-haptic sensory conflict between what users see and feel. This study aimed to investigate how motivation, embodiment, and presence are affected by this visuo-haptic sensory conflict. Using an HMD and a rehabilitation robot, 28 healthy participants performed a path-tracing task, while the robot was either visually reproduced in the VE or not and while the robot either assisted the movements or not. Participants' performance and visual attention were measured during the tasks, and after each visibility/assistance condition, they reported their motivation, presence, and embodiment with questionnaires. We found that, independently of the assistance, the robot visibility did not affect participants' motivation, presence, embodiment, nor task performance. We only found a greater effort/importance reported when the robot was visible. The visual attention was also slightly affected by the robot's visibility. Importantly, we found that the robotic assistance hampered presence and embodiment, but improved motivation. Our results indicate no disadvantage of not reproducing robotic devices in VEs when using HMDs. However, caution must be put when developing assisting controllers, as they might hamper users' affect.
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