Evaluating the effect and mechanism of upper limb motor function recovery induced by immersive virtual-reality-based rehabilitation for subacute stroke subjects: study protocol for a randomized controlled trial

Immersive Virtual Reality in Stroke Rehabilitation: A Systematic Review and Meta-Analysis of Its Efficacy in Upper Limb Recovery

Background: Immersive virtual reality (imVR) has shown promise for upper limb stroke rehabilitation (ULSR). However, optimal implementation and treatment modalities remain unclear. This systematic review and meta-analysis aimed to evaluate imVR's efficacy in ULSR and determine optimal treatment parameters. Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs), comparing imVR to conventional rehabilitation (CR) in adult stroke patients, was conducted. Databases including, the Web of Science, Scopus, and PubMed, were searched. Meta-regression further explored the relationship between intervention duration, frequency, and outcomes. Results: Twenty-three studies were included in the systematic review, representing 395 patients, with thirteen incorporated into the meta-analysis. imVR showed statistically significant improvements in the Fugl-Meyer Assessment Upper Extremity (FMA-UE) Scale (mean difference (MD) = 3.04, 95% CI [1.46; 4.62], p < 0.001) and the Box and Block Test (BBT) (MD = 2.85, 95% CI [0.70; 4.99], p = 0.009) compared to CR, but not in the Action Research Arm Test (ARAT) (MD = 3.47, 95% CI [-0.22; 7.15], p = 0.06). However, these improvements did not reach clinically significant thresholds (7 points for FMA-UE and 6 points for BBT). Clinical subgroup analysis showed significant improvements for both subacute (standardized mean difference (SMD) = 0.92, 95% CI [0.48; 1.36], p = 0.002) and chronic (SMD = 0.69, 95% CI [0.03; 1.35], p = 0.03) stroke stages. Meta-regression indicated that there was a significant positive relationship between the intervention duration and upper limb improvement. Conclusions: imVR demonstrates potential for improving upper limb motor function following stroke, particularly with longer intervention durations and individual session lengths for chronic stroke. However, the improvements observed were not clinically significant, highlighting the need for further research with larger sample sizes and standardized outcome measures to determine optimal treatment protocols.

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.

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 ].

Study of the Possibility of Using Virtual Reality Application in Rehabilitation among Elderly Post-Stroke Patients

Thanks to medical advances, life expectancy is increasing. With it comes an increased incidence of diseases, of which age is a risk factor. Stroke is among these diseases, and is one of the causes of long-term disability. The opportunity to treat these patients is via rehabilitation. A promising new technology that can enhance rehabilitation is virtual reality (VR). However, this technology is not widely used by elderly patients, and, moreover, the elderly often do not use modern technology at all. It therefore becomes a legitimate question whether elderly people will be able to use virtual reality in rehabilitation. This article presents a rehabilitation application dedicated to patients with upper limb paresis and unilateral spatial neglect (USN). The application was tested on a group of 60 individuals including 30 post-stroke patients with an average age of 72.83 years. The results of the conducted study include a self-assessment by the patients, the physiotherapist's evaluation, as well as the patients' performance of the exercise in VR. The study showed that elderly post-stroke patients are able to use virtual reality applications, but the ability to correctly and fully perform an exercise in VR depends on several factors. One of them is the ability to make logical contact (p = 0.0001 < 0.05). However, the study presented here shows that the ability to use VR applications does not depend on age but on mental and physical condition, which gives hope that virtual reality applications can be used in post-stroke rehabilitation among patients of all ages.

Immersive virtual reality-based rehabilitation for subacute stroke: a randomized controlled trial

OBJECTIVE

Few effective treatments improve upper extremity (UE) function after stroke. Immersive virtual reality (imVR) is a novel and promising strategy for stroke UE recovery. We assessed the extent to which imVR-based UE rehabilitation can augment conventional treatment and explored changes in brain functional connectivity (FC) that were related to the rehabilitation.

METHODS

An assessor-blinded, parallel-group randomized controlled trial was performed with 40 subjects randomly assigned to either imVR or Control group (1:1 allocation), each receiving rehabilitation 5 times per week for 3 weeks. Subjects in the imVR received both imVR and conventional rehabilitation, while those in the Control received conventional rehabilitation only. Our primary and secondary outcomes were the Fugl-Meyer assessment's upper extremity subscale (FMA-UE) and the Barthel Index (BI), respectively. Both intention-to-treat (ITT) and per-protocol (PP) analyses were performed to assess the effectiveness of the trial. For both the FMA-UE/BI, a one-way analysis of covariance (ANCOVA) model was used, with the FMA-UE/BI at post-intervention or at follow-up, respectively, as the dependent variable, the two groups as the independent variable, baseline FMA-UE/BI, age, sex, site, time since onset, hypertension and diabetes as covariates.

RESULTS

Both ITT and PP analyses demonstrated the effectiveness of imVR-based rehabilitation. The FMA-UE score was greater in the imVR compared with the Control at the post-intervention (mean difference: 9.1 (95% CI 1.6, 16.6); P = 0.019) and follow-up (mean difference:11.5 (95% CI 1.9, 21.0); P = 0.020). The results were consistent for BI scores. Moreover, brain FC analysis found that the motor function improvements were associated with a change in degree in ipsilesional premotor cortex and ipsilesional dorsolateral prefrontal cortex immediately following the intervention and in ipsilesional visual region and ipsilesional middle frontal gyrus after the 12-week follow-up.

CONCLUSIONS

ImVR-based rehabilitation is an effective tool that can improve the recovery of UE functional capabilities of subacute stroke patients when added to standard care. These improvements were associated with distinctive brain changes at two post-stroke timepoints. The study results will benefit future patients with stroke and provide evidence for a promising new method of stroke rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03086889.

Inclusion of People With Aphasia in Stroke Trials: A Systematic Search and Review

BACKGROUND

Although people with aphasia (PwA) represent 30% of stroke survivors, they are frequently excluded from stroke research, or their inclusion is unclear. Such practice significantly limits the generalizability of stroke research, increases the need to duplicate research in aphasia-specific populations, and raises important ethical and human rights issues.

OBJECTIVE

To detail the extent and nature of inclusion of PwA in contemporary stroke randomized controlled trials (RCTs).

METHODS

We conducted a systematic search to identify completed stroke RCTs and RCT protocols published in 2019. Web of Science was searched using terms "stroke" and "randomized controlled trial". These articles were reviewed by extracting rates of PwA inclusion/exclusion, whether "aphasia" or related terms were referred to in the article or supplemental files, eligibility criteria, consent procedures, adaptations made to support the inclusion of PwA, and attrition rates of PwA. Data were summarized, and descriptive statistics applied when appropriate.

RESULTS

271 studies comprising 215 completed RCTs and 56 protocols were included. 36.2% of included studies referred to aphasia/dysphasia. Of completed RCTs, only 6.5% explicitly included PwA, 4.7% explicitly excluded PwA, and inclusion was unclear in the remaining 88.8%. Among RCT protocols, 28.6% of studies intended inclusion, 10.7% intended excluding PwA, and in 60.7%, inclusion was unclear. In 45.8% of included studies, sub-groups of PwA were excluded, either explicitly (ie, particular types/severities of aphasia, eg, global aphasia) or implicitly, by way of ambiguous eligibility criteria which could potentially relate to a sub-group of PwA. Little rationale for exclusion was provided. 71.2% of completed RCTs did not report any adaptations that could support the inclusion of PwA, and minimal information was provided about consent procedures. Where it could be determined, attrition of PwA averaged 10% (range 0%-20%).

CONCLUSION

This paper details the extent of inclusion of PwA in stroke research and highlights opportunities for improvement.

Effects of Physical Rehabilitation With X-Sens Inertial Technology Feedback on Posterior Cerebral Artery Infarcts: A Case Study

Acute ischemic stroke (AIS) affecting the posterior cerebral artery (PCA) represents a unique clinical challenge, necessitating a multifaceted approach to rehabilitation. This review aims to provide a comprehensive overview of physiotherapeutic interventions tailored specifically for individuals with AIS involving the PCA territory. The PCA supplies critical areas of the brain responsible for visual processing, memory, and sensory integration. Consequently, patients with PCA infarcts often exhibit a distinct set of neurological deficits, including visual field disturbances, cognitive impairments, and sensory abnormalities. This case report highlights evidence-based physiotherapy strategies that encompass a spectrum of interventions, ranging from early mobilization and motor training to sensory reintegration and cognitive rehabilitation. Early mobilization, including bed mobility exercises and upright activities, is crucial to prevent complications associated with immobility. Motor training interventions target the restoration of functional movement patterns, addressing hemiparesis and balance impairments.

Exploring the efficacy of virtual reality-based rehabilitation in stroke: a narrative review of current evidence

BACKGROUND

Stroke rehabilitation presents a complex challenge, necessitating innovative approaches to optimise functional recovery. Virtual Reality-Based Rehabilitation (VRBR) has emerged as a promising intervention that capitalises on immersive technology to engage stroke survivors in their recovery journey. This review aims to examine the efficacy of VRBR in stroke rehabilitation, focusing on its advantages and challenges.

METHODS

A comprehensive search of relevant literature was conducted to gather evidence on the efficacy of VRBR in stroke survivors. Studies that investigated the impact of VRBR on patient engagement, functional recovery, and overall rehabilitation outcomes were included. The review also assessed the ability of VRBR to simulate real-life scenarios and facilitate essential daily activities for stroke survivors.

RESULTS

The review highlights that VRBR offers a unique immersive experience that enhances patient engagement and motivation during rehabilitation. The immersive nature of VRBR fosters a sense of presence, which can positively impact treatment adherence and outcomes. Moreover, VRBR's capacity to replicate real-world scenarios provides stroke survivors with opportunities to practice vital daily activities, promoting functional independence. In contrast, conventional rehabilitation methods lack the same level of engagement and real-world simulation.

CONCLUSION

VRBR holds promise as an efficacious intervention in stroke rehabilitation. Its immersive nature enhances patient engagement and motivation, potentially leading to better treatment adherence and outcomes. The ability of VRBR to simulate real-life scenarios offers a unique platform. However, challenges such as cost, equipment, patient suitability, data privacy, and acceptance must be addressed for successful integration into stroke rehabilitation practice.

Self-Reported Visual Ability Versus Task Performance in Individuals With Ultra-Low Vision

Purpose

Visual functioning questionnaires are commonly used as patient-reported outcome measures to estimate visual ability. Performance measures, on the other hand, provide a direct measure of visual ability. For individuals with ultra-low vision (ULV; visual acuity (VA) <20/1600), the ultra-low vision visual functioning questionnaire (ULV-VFQ) and the Wilmer VRI-a virtual reality-based performance test-estimate self-reported and actual visual ability, respectively, for activities of daily living. But how well do self-reports from ULV-VFQ predict actual task performance in the Wilmer VRI?

Methods

We administered a subset of 10 matching items from the ULV-VFQ and Wilmer VRI to 27 individuals with ULV. We estimated item measures (task difficulty) and person measures (visual ability) using Rasch analysis for ULV-VFQ and using latent variable signal detection theory for the Wilmer VRI. We then used regression analysis to compare person and item measure estimates from self-reports and task performance.

Results

Item and person measures were modestly correlated between the two instruments, with r2 = 0.47 (P = 0.02) and r2 = 0.36 (P = 0.001), demonstrating that self-reports are an imperfect predictor of task difficulty and performance.

Conclusions

While self-reports impose a lower demand for equipment and personnel, actual task performance should be measured to assess visual ability in ULV.

Translational Relevance

Visual performance measures should be the preferred outcome measure in clinical trials recruiting individuals with ULV. Virtual reality can be used to standardize tasks.

Wearable rehabilitation wristband for distal radius fractures

Background

Distal radius fractures are a common type of fracture. For patients treated with closed reduction with splinting, a period of rehabilitation is still required after the removal of the splint. However, there is a general lack of attention and low compliance to rehabilitation training during this period, so it is necessary to build a rehabilitation training monitoring system to improve the efficiency of patients' rehabilitation.

Methods

A wearable rehabilitation training wristband was proposed, which could be used in the patient's daily rehabilitation training scenario and could recognize four common wrist rehabilitation actions in real-time by using three thin film pressure sensors to detect the pressure change curve at three points on the wrist. An algorithmic framework for classifying rehabilitation training actions was proposed. In our framework, an action pre-detection strategy was designed to exclude false detections caused by switching initial gestures during rehabilitation training and wait for the arrival of the complete signal. To classify the action signals into four categories, firstly an autoencoder was used to downscale the original signal. Six SVMs were then used for evaluation and voting, and the final action with the highest number of votes would be used as the prediction result.

Results

Experimental results showed that the proposed algorithmic framework achieved an average recognition accuracy of 89.62%, an average recognition recall of 88.93%, and an f1 score of 89.27% on the four rehabilitation training actions.

Conclusion

The developed device has the advantages of being small size and easy to wear, which can quickly and accurately identify and classify four common rehabilitation training actions. It can easily be combined with peripheral devices and technologies (e.g., cell phones, computers, Internet) to build different rehabilitation training scenarios, making it worthwhile to use and promote in clinical settings.

Virtual reality applications for rehabilitation of COVID-19 patients: A systematic review

Background and Aims

The COVID-19 pandemic has changed people's lifestyles as well as the way healthcare services are delivered. Undoubtedly, the difficulties associated with COVID-19 infection and rehabilitation and those associated with quarantine and viral preventive efforts may exacerbate the need for virtual reality to be used as a part of a complete rehabilitation strategy for these individuals. Thus, the present research aimed to evaluate the potential uses of virtual reality for the rehabilitation of individuals suffering from COVID-19.

Methods

From 2019 to March 1, 2022, a systematic search was conducted in PubMed, Cochran Library, Scopus, Science Direct, ProQuest, and Web of Science databases. The papers were selected based on search terms and those that discussed the use of virtual reality in the rehabilitation of COVID-19 patients were reviewed. Each step of the study was reviewed by two authors.

Results

A total of 699 papers were found during the first search. Three papers were chosen for further investigation after a thorough evaluation of the publications' titles, abstracts, and full texts. Cross-sectional studies, randomized controlled clinical trials, and case reports comprised 33%, 33%, and 33% of the publications, respectively. Based on the results, people suffering from COVID-19 were the focus of two papers (66%) that employed immersion virtual reality for cognitive rehabilitation, whereas one study (33%) used non-immersive virtual reality for physical rehabilitation. In two papers (66%), virtual reality was also offered to patients in the form of a game.

Conclusion

According to the results of the present research, virtual reality games may enhance functional and cognitive consequences, contentment levels among patients, and their ability to take charge of their own health care. In light of the obstacles faced by COVID-19 patients, alterations in the delivery of healthcare, and the significance of rehabilitation in this group during quarantine, new techniques have been considered for these patients to maintain treatment, return to regular life, and enhance their standard of life.

HRpI System Based on Wavenet Controller with Human Cooperative-in-the-Loop for Neurorehabilitation Purposes

There exist several methods aimed at human-robot physical interaction (HRpI) to provide physical therapy in patients. The use of haptics has become an option to display forces along a given path so as to it guides the physiotherapist protocol. Critical in this regard is the motion control for haptic guidance to convey the specifications of the clinical protocol. Given the inherent patient variability, a conclusive demand of these HRpI methods is the need to modify online its response with neither rejecting nor neglecting interaction forces but to process them as patient interaction. In this paper, considering the nonlinear dynamics of the robot interacting bilaterally with a patient, we propose a novel adaptive control to guarantee stable haptic guidance by processing the causality of patient interaction forces, despite unknown robot dynamics and uncertainties. The controller implements radial basis neural network with daughter RASP1 wavelets activation function to identify the coupled interaction dynamics. For an efficient online implementation, an output infinite impulse response filter prunes negligible signals and nodes to deal with overparametrization. This contributes to adapt online the feedback gains of a globally stable discrete PID regulator to yield stiffness control, so the user is guided within a perceptual force field. Effectiveness of the proposed method is verified in real-time bimanual human-in-the-loop experiments.

Rapid Synthesis of the Literature on the Evolution of Gamification in Distal Radial Fracture Rehabilitation

Distal radial fractures (DRF) are often encountered in upper limb fractures globally, and their associated complications affect the functional independence of the individual following the injury. The potential of gamification in applied rehabilitation is expanding its horizons in the rehabilitation of conditions ranging from neuromotor deficits to cognitive impairments. However, the synthesis of the literature is aimed at analyzing and summarizing the evolution of gamification in DRF rehabilitation. A comprehensive search and extraction of relevant literature were conducted and reviewed for the applicability of population analysis, interventional methodology, comparative factors, outcome measures, and the type of study. Thirteen studies were included and evaluated, including randomized controlled trials (RCTs), literature reviews, systematic reviews, meta-analyses, and bibliometric analyses. The conclusions demonstrated an improvement with gamification and addressed it as an effective rehabilitation method. Based on the analysis of the data that was extracted, the conclusion supports the use of gamification in the rehabilitation of DRF and looks into how it can help improve the person's functional capacity.

The effects of a combination of 3D virtual reality and hands-on horticultural activities on mastery, achievement motives, self-esteem, isolation and depression: a quasi-experimental study

Background

Aging societies are a public health concern worldwide. It is critical to develop strategies that harness technology to enhance older adults’ mastery, achievement motives, self-esteem, isolation and depression effectively.

Methods

This study aimed to explore the effects of a combination of three-dimensional virtual reality (VR) and hands-on horticultural activities on the psychological well-being of community-dwelling older adults. We used a quasi-experimental design. A total of 62 community-dwelling older adults were recruited and assigned to the experimental (n = 32) and comparison groups (n = 30). The members of the experimental group participated in an 8-week intervention program. Participants of both groups completed before-and-after intervention measurements for outcome variables that included perceived self-esteem, depression, isolation, and mastery and achievement motives, which were analyzed using the generalized estimating equation (GEE). A baseline score of depression was used as an adjustment for the GEE analyses to eliminate the effects of depression on outcomes.

Results

After controlling age and gender as confounders, GEE analyses indicated that the experimental group showed significant post-intervention improvements in scores for self-esteem (β = 2.18, P = .005) and mastery (β = 1.23, P = .039), compared to the control group.

Conclusions

This study supported a combination of three-dimensional VR and hands-on horticultural activities on community-dwelling older adults to improve self-esteem and mastery. The findings suggest that the future implementation of a similar program would be feasible and beneficial to community-dwelling older adults.

Trial registration

The study was posted on www.clinicaltrials.gov (NCT05087654) on 21/10/2021. It was approved by the Institutional Review Board of En Chu Kong Hospital and performed in accordance with the Declaration of Helsinki.

A research protocol on leap motion tracking device: A novel intervention method in distal radial fracture rehabilitation

Introduction

Physiotherapeutic rehabilitation are used to optimize functional recovery following a distal radial fracture (DRF). Being most common upper limb fracture in all age groups, the DRF peaks in young men and in post-menopausal women with incidence ratio of 1:4. Leap motion control based rehabilitation of patients with DRF is limited. This research aims to assess the efficacy of leap motion control based rehabilitation in patients with DRF.

Methods

In an randomized parallel group trial, subjects (n = 40) with DRF will be recruited. The participants will be enrolled into either experimental or control group with 1:1 allocation ratio. Following the primary assessment and allocation, the participants in experimental group will receive both leap motion control and conventional therapy over a period of six weeks. Participants in conventional group would undergo only conventional therapy. The primary outcome measures will be Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and Universal goniometer however the grip strength and Visual Analog Scale (VAS) will be used as secondary outcome measures.

Purpose of the study

The findings of this trial will examine the impact of leap motion control in DRF patients with conventional therapy on improving the functional activity, range of motion (ROM), grip strength and pain.

Expected clinical implications

To conclude, this research seeks to examine the rapid and long term effects of leap motion control in DRF patients. The study findings would help prospective patients with DRF, which may include a newly designed approach of rehabilitation.

The effect of early systematic rehabilitation nursing on the quality of life and limb function in elderly patients with stroke sequelae

OBJECTIVE

To study the effect of early systematic rehabilitation nursing on the quality of life and limb function in elderly patients with stroke sequelae.

METHODS

This prospective study was conducted in 97 elderly patients with stroke sequelae. These patients were randomly allocated to the control group (n=49) and the experimental group (n=48). Patients in the control group received routine rehabilitation nursing, while those in the experimental group received early systematic rehabilitation nursing. Upper limb motor function (Fugl-Meyer assessment (FMA) score), upper limb sensory function (tactile threshold and two-point discrimination), physiological state (Hamilton anxiety (HAMA) scale and Hamilton depression (HAMD) scale score), ability of daily living (ADL) (the Barthel index score and ability of daily living score), and the quality of life (generic quality of life inventory-74 (GQOLI-74) score) before and 3 months after intervention were compared between the two groups.

RESULTS

Compared with before intervention, FMA scores in the two groups after intervention were increased, while modified Ashworth scores were decreased (all P<0.05). The changes in the experimental group after intervention were more than those in the control group (both P<0.05). Tactile threshold and two-point discrimination in both groups after intervention were reduced when compared with before intervention (all P<0.05); tactile threshold and two-point discrimination in the experimental group after intervention group were smaller than those in the control group (both P<0.05). HAMA scale and HAMD scale scores in the two groups after intervention were lower than those before intervention (all P<0.05); HAMA scale and HAMD scale score in the experimental group after intervention were reduced when compared with the control group (both P<0.05). The Barthel index scores, ADL scores, and GQOLI-74 scores in both groups after intervention were increased when compared with before intervention (all P<0.05). The Barthel index score, ADL score, and GQOLI-74 score in the experimental group after intervention were higher than those in the control group (all P<0.05).

CONCLUSION

For elderly patients with stroke sequelae, early systemic rehabilitation nursing is more beneficial for the improvement of upper limb motor and sensory function, alleviation of negative psychology, raise in ability of daily living, and increase of life quality. It is therefore worthy of clinical application.

Effect of Immersive Virtual Reality-Based Bilateral Arm Training in Patients with Chronic Stroke

Virtual reality (VR)-based therapies are widely used in stroke rehabilitation. Although various studies have used VR techniques for bilateral upper limb training, most have been only semi-immersive and have only been performed in an artificial environment. This study developed VR content and protocols based on activities of daily living to provide immersive VR-based bilateral arm training (VRBAT) for upper limb rehabilitation in stroke patients. Twelve patients with chronic stroke were randomized to a VRBAT group or a normal bilateral arm training (NBAT) group and attended 30-min training sessions five times a week for four weeks. At the end of the training, there was a significant difference in upper limb function in both groups (p < 0.05) and in the upper limb function sensory test for proprioception in the NBAT group (p < 0.05). There was no significant between-group difference in upper limb muscle activity after training. The relative alpha and beta power values for electroencephalographic measurements were significantly improved in both groups. These findings indicate that both VRBAT and NBAT are effective interventions for improving upper limb function and electroencephalographic activity in patients with chronic stroke.

What External Variables Affect Sensorimotor Rhythm Brain-Computer Interface (SMR-BCI) Performance?

Description Sensorimotor rhythm-based brain-computer interfaces (SMR-BCIs) are used for the acquisition and translation of motor imagery-related brain signals into machine control commands, bypassing the usual central nervous system output. The selection of optimal external variable configuration can maximize SMR-BCI performance in both healthy and disabled people. This performance is especially important now when the BCI is targeted for everyday use in the environment beyond strictly regulated laboratory settings. In this review article, we summarize and critically evaluate the current body of knowledge pertaining to the effect of the external variables on SMR-BCI performance. When assessing the relationship between SMR-BCI performance and external variables, we broadly characterize them as elements that are less dependent on the BCI user and originate from beyond the user. These elements include such factors as BCI type, distractors, training, visual and auditory feedback, virtual reality and magneto electric feedback, proprioceptive and haptic feedback, carefulness of electroencephalography (EEG) system assembling and positioning of EEG electrodes as well as recording-related artifacts. At the end of this review paper, future developments are proposed regarding the research into the effects of external variables on SMR-BCI performance. We believe that our critical review will be of value for academic BCI scientists and developers and clinical professionals working in the field of BCIs as well as for SMR-BCI users.

VIRTUAL REALITY TRAINING THROUGH NINTENDO WII GAMES IN STROKE PATIENTS: A RANDOMISED CLINICAL TRIAL (Preprint)

Background

Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial.

Objective

The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke.

Methods

It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22.

Results

The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted.

Conclusions

VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability.

Trial Registration

Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view

[Speech and spatial characteristics of hearing in older age groups using virtual reality technologies]

Spatial and speech characteristics of hearing are needed to monitor the rehabilitation of sensorineural hearing loss in patients of older age groups. Using the created «Program for the assessment of speech, spatial and qualitative characteristics of hearing using virtual reality» increases the level of hearing diagnostics using a computerized audiovisual script. The purpose of the study is a comparative analysis of the speech, spatial and qualitative characteristics of hearing before and after using virtual reality in patients of older age groups. The results of the study showed that with good tolerance of virtual reality in 48.3% of patients, the answers to the questions of the SSQrus-12 questionnaire for assessing the spatial and speech characteristics of hearing became more objective. The developed methodology supplemented the group of modern diagnostic methods for spatial and verbal hearing by immersing the patient in a virtual environment in the created audiovisual scenario.

Immersive virtual reality in children with upper limb injuries: Findings from a feasibility study

PURPOSE

Children who sustain Upper Limb Injuries (ULIs), including fractures and burns, may undergo intensive rehabilitation. The discomfort of therapy can reduce their compliance, limit their range of motion (ROM) and lead to chronic pain. Virtual Reality (VR) interventions have been found to reduce anticipated and procedural pain.This feasibility study aimed to explore perceptions and impacts of a custom-made, fully immersive Head-Mounted Display VR (HMD-VR) experience within a United Kingdom (UK) National Health Service (NHS) outpatient rehabilitation service for children with ULIs.

METHODS

Ten children aged 9-16 in one UK Children's hospital trialled HMD-VR during one rehabilitation session. They, their parents (n = 10), and hospital physiotherapy staff (n = 2) were interviewed about their perceptions of pain, difficulty, enjoyability, therapeutic impacts, benefits, and limitations. Children rated the sessions on enjoyability, difficulty, and pain compared to usual rehabilitation exercises. Physiotherapists were asked to provide range of motion readings.

RESULTS

Inductive thematic analysis of interview data generated three themes, 'Escape through Engagement'; 'Enhanced Movement'; and 'Adaptability and Practicality'. Children rated the session as more enjoyable, less difficult and painful than their usual rehabilitation exercises. Findings suggested that HMD-VR was an engaging, enjoyable experience that distracted children from the pain and boredom of therapy. Also, it seemed to enhance the movement they achieved. Participants perceived it was useful for rehabilitation and adaptable to individual needs and other patient groups. Suggestions were made to increase adaptability and build in practical safeguards.

CONCLUSION

Findings from this small-scale feasibility study suggested HMD-VR was perceived as usable, acceptable, and effective with potential for further development. Future work could include larger scale trials.

Head-Mounted Display-Based Application for Cognitive Training

Virtual Reality (VR) has had significant advances in rehabilitation, due to the gamification of cognitive activities that facilitate treatment. On the other hand, Immersive Virtual Reality (IVR) produces outstanding results due to the interactive features with the user. This work introduces a VR application for memory rehabilitation by walking through a maze and using the Oculus Go head-mounted display (HMD) technology. The mechanics of the game require memorizing geometric shapes while the player progresses in two modes, autonomous or manual, with two levels of difficulty depending on the number of elements to remember. The application is developed in the Unity 3D video game engine considering the optimization of computational resources to improve the performance in the processing and maintaining adequate benefits for the user, while the generated data is stored and sent to a remote server. The maze task was assessed with 29 subjects in a controlled environment. The obtained results show a significant correlation between participants’ response accuracy in both the maze task and a face–pair test. Thus, the proposed task is able to perform memory assessments.

[New perspectives of motor rehabilitation of patients after focal brain lesions]

Rehabilitation of patients after focal brain lesions is one of the topical issues of modern medicine. Motor disorders are known to develop in more than 80% of survivors of stroke and traumatic brain injury and be one of the main causes of disability, which necessitates an active search for new effective techniques for correction of motor disorders. Modern rehabilitation includes both traditional techniques for recovery of patients with motor deficit (exercise therapy and physiotherapy) and botulinum therapy, kinesiotherapy, mechanotherapy, etc., which have been developed in recent years. Robotic technologies have been developed, improved, and implemented. Currently, due to progress in computerization, virtual reality-based rehabilitation of patients is of particular interest. The article reviews the key studies in this field. We describe various visualization methods and means of immersion in a virtual environment for recovery of upper and lower extremity function in patients with focal brain lesions. The study provides an assessment of the effectiveness and safety of various virtual reality-based rehabilitation programs in patients with motor disorders after stroke and traumatic brain injury.

Effect of Leap Motion-based 3D Immersive Virtual Reality Usage on Upper Extremity Function in Ischemic Stroke Patients

Immersive virtual reality (VR) is a technology that provides a more realistic environmental design and object tracking than ordinary VR. The aim of this study was to investigate the effectiveness of immersive VR on upper extremity function in patients with ischemic stroke. Sixty-five patients with ischemic stroke were included in this randomized, controlled, double-blind study. Patients were randomly divided into VR (n = 33) and control (n = 32) groups. The VR group received 60 minutes of the upper extremity immersive VR rehabilitation program and the control group received 45 minutes of conventional therapy and 15 minutes of a sham VR program. Rehabilitation consisted of 18 sessions of therapy, three days per week, for six weeks. The outcome measures were the Action Research Arm Test (ARAT), Functional Independence Measure (FIM), Fugl-Meyer Upper Extremity Scale (FMUE) and Performance Assessment of Self-Care Skills (PASS). In both the VR and control groups all parameters except the PASS improved over time. However independent t-test results showed that all of the FMUE, ARAT, FIM and PASS scores were significantly higher in the VR group compared with the control (p < 0.05). The minimal clinically important difference (MCID) scores of the FMUE and ARAT were higher than the cut-off MCID scores described in the literature in the VR group, whereas the FIM scores were below the cut-off MCID scores. All scores in the control group were below the cut-off scores. Immersive VR rehabilitation appeared to be effective in improving upper extremity function and self-care skills, but it did not improve functional independence.