Walking with head-mounted virtual and augmented reality devices: Effects on position control and gait biomechanics

An Interactive Vision-Based 3D Augmented Reality System for In-Home Physical Rehabilitation: A Qualitative Inquiry to Inform System Development

BACKGROUND

Postoperative physical rehabilitation is crucial after total joint replacement (TJR). However, completing the recommended levels of postoperative physical exercise is challenging for many older adults with TJR. Lack of adequate postoperative physical exercise has negative consequences on rehabilitation outcomes. Innovative rehabilitation tools for postoperative physical exercises are needed to ensure successful rehabilitation outcomes among older adults with TJR.

OBJECTIVE

The aim of this study is to explore key knowledge users' perspectives about how to design an interactive vision-based three-dimensional augmented reality system (3D ARS) to support in-home postoperative physical rehabilitation for older adults with TJR.

METHODS

We conducted a qualitative descriptive study involving 11 semi-structured interviews and six focus groups with 42 older adults with TJR and four unrelated family caregivers. Data were analysed using thematic analysis.

RESULTS

Participant insights were grouped into two main themes: (1) dreaming up possibilities and (2) being pragmatic. The first theme captured participants' reflections on the potential utility of a 3D ARS for postoperative physical rehabilitation and features that could be embedded in the 3D ARS to support successful postoperative physical rehabilitation. The second theme captured participants' reflections on practical issues and considerations that could impact access and usage of the 3D ARS.

CONCLUSION

These findings provide researchers, rehabilitation providers and system developers with the foundations for designing, implementing and evaluating innovative augmented reality tools that support effective in-home physical rehabilitation among older adults with TJR.

PATIENT OR PUBLIC CONTRIBUTION

Research users (i.e., individuals and organisations invested in and using the research findings) were actively engaged throughout this work. Specifically, a meeting was held between the research team and representatives of an Expert by Experience team (individuals with lived experience), which was established to support the National Research Council's (organisation) Aging in Place programme. During this meeting, the idea to develop and evaluate an ARS for postoperative physical rehabilitation of older adults with TJR was supported. Research users had the opportunity to review the current study protocol and provide feedback on the study design, offering direction to maximize the relevance and usefulness of our findings to the National Research Council Canada's Aging in Place programme. Research users contributed to participant recruitment efforts and the development of the interview guide. Two Experts by Experience also agreed to be on the Advisory Panel for this multi-phased study, supporting active engagement and centring the voice of research users in knowledge creation and implementation. These experts reviewed a brief report of the current study findings, and continue to guide how the study findings are used to inform the next phase of this multi-phased research.

Walking on Virtual Surface Patterns Leads to Changed Control Strategies

Inclusive design does not stop at removing physical obstacles such as staircases. It also involves identifying architectural features that impose sensory burdens, such as repetitive visual patterns that are known to potentially cause dizziness or visual discomfort. In order to assess their influence on human gait and its stability, three repetitive patterns-random dots, repetitive stripes, and repetitive waves (Lisbon pattern)-were displayed in a coloured and greyscale variant in a virtual reality (VR) environment. The movements of eight participants were recorded using a motion capture system and electromyography (EMG). During all test conditions, a significant increase in the muscular activity of leg flexor muscles was identified just before touchdown. Further, an increase in the activity of laterally stabilising muscles during the swing phase was observed for all of the test conditions. The lateral and vertical centre of mass (CoM) deviation was statistically evaluated using a linear mixed model (LMM). The patterns did cause a significant increase in the CoM excursion in the vertical direction but not in the lateral direction. These findings are indicative of an inhibited and more cautious gait style and a change in control strategy. Furthermore, we quantified the induced discomfort by using both algorithmic estimates and self-reports. The Fourier-based methods favoured the greyscaled random dots over repetitive stripes. The colour metric favoured the striped pattern over the random dots. The participants reported that the wavey Lisbon pattern was the most disruptive. For architectural and structural design, this study indicates (1) that highly repetitive patterns should be used with care in consideration of their impact on the human visuomotor system and its behavioural effects and (2) that coloured patterns should be used with greater caution than greyscale patterns.

Application of immersive virtual reality in the training of wheelchair boxers: evaluation of exercise intensity and users experience additional load- a pilot exploratory study

BACKGROUND

Over the last few years, there has been a growing interest in workout apps and active virtual reality video games (AVRGs), which provide entertainment and enable users to undertake various forms of physical activity (PA) at home. Presumably, these types of exercises can be particularly useful for people with physical disabilities, who experience problems with access to sports and leisure facilities due to architectural and communication barriers. However, it is interesting whether the intensity of PA in VR is high enough to provide users with health benefits, as it is mainly based on arm movements.

OBJECTIVE

The main aim of the study was to evaluate the intensity of physical exercise of wheelchair boxers during a boxing training session using the FitXR app in immersive VR in light of health-related PA recommendations. The effect of Velcro-fastened hand-held weights (HHWs) on the intensity of PA undertaken by people in VR was also examined, and the attractiveness of virtual exercise were assessed in the opinion of users.

METHODS

PA intensity was evaluated using a heart rate monitor based on the percentage of maximal heart rate (% HRmax) and the Borg's rating of perceived exertion (RPE 6-20). The attractiveness perceived during exercise by users were evaluated using the Physical Activity Enjoyment Scale (PACES 1-7 scale).

RESULTS

The study shows that the exercise intensity of the athletes during wheelchair boxing training in VR is at a beneficial moderate level for health (HRave=68.98% HRmax). The use of HHWs (0.5 kg) does not significantly increase the PA intensity of the individuals during virtual exercise. Users with disabilities highly rated the attractiveness (6.32 ± 0.79 points) of PA during virtual boxing training.

CONCLUSIONS

Boxing exercises in VR can be an attractive and health-related form of PA for wheelchair boxers and a supplement to their conventional training.

Postoperative rehabilitation using a digital healthcare system in patients with total knee arthroplasty: a randomized controlled trial

INTRODUCTION

Digital healthcare systems based on augmented reality (AR) show promise for postoperative rehabilitation. We compared the effectiveness of AR-based rehabilitation and conventional rehabilitation after total knee arthroplasty (TKA).

MATERIALS AND METHODS

We randomly allocated 56 participants to digital healthcare rehabilitation group (DR group) and conventional rehabilitation group (CR group). Participants in the CR group performed brochure-based home exercises for 12 weeks, whereas those in the DR group performed AR-based home exercises that showed each motion on a monitor and provided real-time feedback. The primary outcome was change in 4-m gait speed. The secondary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, health-related quality of life [assessed by the EuroQoL 5-Dimension 5-Level (EQ5D5L) questionnaire], pain [measured using a numeric rating scale (NRS)], Berg Balance Scale (BBS), range of motion (ROM), and muscle strength. Outcomes were measured at baseline (T0) and 3 (T1), 12 (T2), and 24 (T3) weeks after randomization.

RESULTS

There was no significant difference in baseline characteristics of participants between two groups, except age and body mass index. No group difference was observed in 4-m gait speed (0.37 ± 0.19 and 0.42 ± 0.28 for the DR and CR groups, respectively; p = 0.438). The generalized estimating equation model revealed no significant group by time interaction regarding for 4-m gait speed, WOMAC, EQ5D5L, NRS, BBS, ROM, and muscle strength score. All outcomes were significantly improved in both groups (p < 0.001).

CONCLUSION

The use of a digital healthcare system based on AR improved the functional outcomes, pain, and quality of life of patients after TKA. AR-based rehabilitation may be useful treatment as an alternative to conventional rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov (identifier: NCT04513353). Registered on August 9, 2020. http://clinicaltrials.gov/ct2/show/NCT04513353 .

Alterations in Physical Demands During Virtual/Augmented Reality-Based Tasks: A Systematic Review

The digital world has recently experienced a swift rise in worldwide popularity due to Virtual (VR) and Augmented Reality (AR) devices. However, concrete evidence about the effects of VR/AR devices on the physical workload imposed on the human body is lacking. We reviewed 27 articles that evaluated the physical impact of VR/AR-based tasks on the users using biomechanical sensing equipment and subjective tools. Findings revealed that movement and muscle demands (neck and shoulder) varied in seven and five studies while using VR, while in four and three studies during AR use, respectively, compared to traditional methods. User discomfort was also found in seven VR and three AR studies. Outcomes indicate that interface and interaction design, precisely target locations (gestures, viewing), design of virtual elements, and device type (location of CG as in Head-Mounted Displays) influence these alterations in neck and shoulder regions. Recommendations based on the review include developing comfortable reach envelopes for gestures, improving wearability, and studying temporal effects of repetitive movements (such as effects on fatigue and stability). Finally, a guideline is provided to assist researchers in conducting effective evaluations. The presented findings from this review could benefit designers/evaluations working towards developing more effective VR/AR products.

Integration of Square Fiducial Markers in Patient-Specific Instrumentation and Their Applicability in Knee Surgery

Computer technologies play a crucial role in orthopaedic surgery and are essential in personalising different treatments. Recent advances allow the usage of augmented reality (AR) for many orthopaedic procedures, which include different types of knee surgery. AR assigns the interaction between virtual environments and the physical world, allowing both to intermingle (AR superimposes information on real objects in real-time) through an optical device and allows personalising different processes for each patient. This article aims to describe the integration of fiducial markers in planning knee surgeries and to perform a narrative description of the latest publications on AR applications in knee surgery. Augmented reality-assisted knee surgery is an emerging set of techniques that can increase accuracy, efficiency, and safety and decrease the radiation exposure (in some surgical procedures, such as osteotomies) of other conventional methods. Initial clinical experience with AR projection based on ArUco-type artificial marker sensors has shown promising results and received positive operator feedback. Once initial clinical safety and efficacy have been demonstrated, the continued experience should be studied to validate this technology and generate further innovation in this rapidly evolving field.

Global trends and hotspots in research on extended reality in sports: A bibliometric analysis from 2000 to 2021

Objective

Extended reality technologies (e.g. virtual reality (VR), augmented reality (AR) and mixed reality (MR)) are gaining popularity in sports owing to their unique advantages. This study aims to analyse the progress of the application of extended reality technology in sports and reveal its cooperative features, research hotspots and development trends.

Methods

We searched the literature in the Web of Science Core Collection (WoSCC) database within the period 2000 to 2021 and conducted a bibliometric analysis. The analysis methods included statistical, co-occurrence, hierarchical clustering and social network analyses.

Results

A total of 340 articles were gathered. The literature related to its research showed an increasing trend over time. The paper collaboration rate was 90.88% (309/340 papers), and the degree of author collaboration was 3.96 (1345/340). VR was found to be the most productive journal, and Queen's University Belfast was the most productive institution. The United States, China and the United Kingdom were the three main contributors to the field. The foundational themes in sports extended reality research were (i) sports games and extended reality systems, (ii) virtual simulation devices and artificial intelligence, (iii) sports training and performance and (iv) age-appropriate physical activity, sports rehabilitation and physical education.

Conclusion

The level of author collaboration was low, but the degree of author collaboration is largely on the rise. The closeness of the collaboration between institutions and countries was also low. In addition, the subject of sport extended reality is relatively fragmented. Therefore, more research is needed to strengthen it in the future.

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.

Gamification for Distal Radius Fracture Rehabilitation: A Randomized Controlled Pilot Study

Introduction

Gamification is a novel interventional approach to functional recovery and rehabilitation. A significant impact has been observed with the application of gamification on non-traumatic conditions and chronic neurological and musculoskeletal illnesses; however, the implication of gamification on the functional recovery of patients with distal radius fractures (DRF) is yet to be explored. 

Methodology

This pilot study included 20 post-DRF patients aged 18-65 years with unilateral DRF, managed with closed reduction and K-wire internal fixation. The patients were assigned to group A (gamification) and group B (conventional rehabilitation) in a 1:1 ratio. Group A patients played Racket: NX game, Until you fall game, and Holofit game on Oculus Quest head-mounted display (HMD) (Oculus, USA), while group B patients received a conventional rehabilitation program. Both groups underwent a rehabilitation program for 60 min/day, five days a week, for four weeks. The visual analogue scale (VAS), universal goniometer, Jamar dynamometer, and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire were used as outcome measures at baseline, at the end of the second week, and at the end of treatment.

Results

There were significant improvements in pain, range of motion (ROM), grip strength, and functional independence in both groups. However, improvements in hand function and functional independence were significantly greater in the gamification group than in the conventional physiotherapy rehabilitation group.

Conclusion

The study concluded that gamification appears to have a significant impact on post-DRF rehabilitation in terms of pain, ROM, grip strength, and functional independence. Further research with larger sample sizes is required to confirm the preliminary findings.

Surgery Training and Simulation Using Virtual and Augmented Reality for Knee Arthroplasty

A range of extended reality technology integration, including immersive virtual reality (IVR), augmented reality (AR), as well as mixed reality, has lately acquired favour in orthopaedics. The utilization of extended reality machinery in knee arthroplasty is examined in this review study. Virtual reality (VR) and AR are usually exercised together in orthopaedic surgical training as alluring training outside of the operation theatre is acknowledged as a good surgical training tool. The use of this technology, its consequences for orthopaedic surgeons and their patients, and its moral and practical issues are also covered. Head-mounted displays (HMDs) are a potential addition directed toward improving surgical precision along with instruction. Although the hardware is cutting-edge, substantial effort needs to be done to develop software that enables seamless, trustworthy integration into clinical practice and training. Remote virtual rehabilitation has drawn increasing attention in recent years, and its significance has increased in light of the recent outbreak of the COVID-19 epidemic. Numerous medical sectors have shown the benefits of telerehabilitation, gamification, VR, and AR. Given the rising demand for orthopaedic therapy and its rising costs, this is a requirement. A remote surgeon can impart knowledge without being present, by virtually placing his or her hands in the visual field of a local surgeon using AR technology. With the use of this innovation, orthopaedic surgery seems to have been able to participate in the telemedicine revolution. This technology may also have an impact on how surgeons collaborate and train for orthopaedic residencies in the future. Volatility in the HMD market will probably stall improvements in surgical education.

Effectiveness of Augmented Reality for Lower Limb Rehabilitation: A Systematic Review

Augmented reality- (AR-) based interventions have shown potential benefits for lower limb rehabilitation. However, current literature has not revealed these benefits as a whole. The main purposes of this systematic review were to determine the efficacy of AR-based interventions on lower limb recovery of the larger population based on the current process that has been made in this regard. Relevant studies were retrieved from five electronic databases (Web of Science, PubMed, ScienceDirect, Scopus, and Cochrane Library) using “augmented reality” OR “AR” AND “lower limb” OR “lower extremity” AND “intervention” OR “treatment”. Sixteen studies that met the eligibility criteria were included in this review, and they were further grouped into three categories based on the participant types. Seven studies focused on the elderly adults, six on the stroke patients, and the last three on Parkinson patients. Based on the findings of these trials, the significant effects of AR-based interventions on lower limb rehabilitation (i.e., balance, gait, muscle, physical performance, and fall efficacy) have been initially confirmed. Favorable results were achieved at least the same as the interventions without AR except for the turning and timing in the freezing of gait of Parkinson patients. However, given the infancy of this technology in clinical practices, more robust trials with larger sample sizes and greater homogeneity in terms of devices and treatment settings are warranted for further verification.

A gamified augmented reality vocational training program for adults with intellectual and developmental disabilities: A pilot study on acceptability and effectiveness

OBJECTIVES

The Augmented Reality Games to Enhance Vocational Ability of Patients (REAP) was an augmented reality vocational training program that provided skills training in the context of a psychiatric rehabilitation program. It was implemented over 10 weeks and consisted of gamified augmented reality café training scenarios and bridging group activities to facilitate transfer of learning to the work context. This pilot study aimed to explore the acceptability and effectiveness of the REAP program when carried out with adults with intellectual and developmental disabilities attending work therapy. Its objectives were: (1) to obtain feedback from participants and trainers on their experiences and acceptability of the REAP program and (2) to measure changes in vocational and cognitive skills of participants in the REAP program.

MATERIALS AND METHODS

This was a pretest-posttest mixed methods study. 15 adults with intellectual and developmental disabilities attending work therapy in a non-profit organization participated in the REAP program and their vocational trainers were involved in assisting in this program. Feasibility Evaluation Checklist (FEC) and the Neurobehavioral Cognitive Status Exam (Cognistat) were administered at baseline, post-training and eight weeks after training. The participants and their trainers also provided user feedback via semi-structured interviews.

RESULTS

Majority of the participants and trainers found the REAP program to be useful and interesting. They also found that the augmented reality games were user-friendly and provided a unique opportunity to acquire new skills. Participants who engaged in this program showed a significant improvement in vocational skills and aspects of cognitive skills, which were maintained eight weeks after training.

CONCLUSION

The gamified augmented reality vocational training was feasible and accepted by both adults with intellectual and developmental disabilities and their trainers. When integrated with bridging sessions to facilitate transfer of learning to existing work therapy, participants on the REAP program showed significant improvements in vocational skills and aspects of cognitive skills. Future experimental studies with larger sample size could provide stronger evidence on its effectiveness in improving vocational outcomes.

Augmented Reality in Physical Therapy: Systematic Review and Meta-analysis

Background

Augmented reality (AR) is a rapidly expanding technology; it comprises the generation of new images from digital information in the real physical environment of a person, which simulates an environment where the artificial and real are mixed. The use of AR in physiotherapy has shown benefits in certain areas of patient health. However, these benefits have not been studied as a whole.

Objective

This study aims to ascertain the current scientific evidence on AR therapy as a complement to physiotherapy and to determine the areas in which it has been used the most and which variables and methods have been most effective.

Methods

A systematic review registered in PROSPERO (International Prospective Register of Systematic Reviews) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) recommendations. The search was conducted from July to August 2021 in the PubMed, PEDro, Web of Science, Scopus, and Cochrane Library scientific databases using the keywords augmented reality, physiotherapy, physical therapy, exercise therapy, rehabilitation, physical medicine, fitness, and occupational therapy. The methodological quality was evaluated using the PEDro scale and the Scottish Intercollegiate Guidelines Network scale to determine the degree of recommendation. The Cochrane Collaboration tool was used to evaluate the risk of bias.

Results

In total, 11 articles were included in the systematic review. Of the 11 articles, 4 (36%) contributed information to the meta-analysis. Overall, 64% (7/11) obtained a good level of evidence, and most had a B degree of recommendation of evidence. A total of 308 participants were analyzed. Favorable results were found for the Berg Balance Scale (standardized mean change 0.473, 95% CI −0.0877 to 1.0338; z=1.65; P=.10) and the Timed Up and Go test (standardized mean change −1.211, 95% CI −3.2005 to 0.7768; z=−1.194; P=.23).

Conclusions

AR, in combination with conventional therapy, has been used for the treatment of balance and fall prevention in geriatrics, lower and upper limb functionality in stroke, pain in phantom pain syndrome, and turning in place in patients with Parkinson disease with freezing of gait. AR is effective for the improvement of balance; however, given the small size of the samples and the high heterogeneity of the studies, the results were not conclusive. Future studies using larger sample sizes and with greater homogeneity in terms of the devices used and the frequency and intensity of the interventions are needed.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020180766; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=180766

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.

A Review of the Potential of Virtual Walking Techniques for Gait Rehabilitation

Virtual reality (VR) technology has emerged as a promising tool for studying and rehabilitating gait disturbances in different cohorts of patients (such as Parkinson's disease, post-stroke, or other neurological disorders) as it allows patients to be engaged in an immersive and artificial environment, which can be designed to address the particular needs of each individual. This review demonstrates the state of the art in applications of virtual walking techniques and related technologies for gait therapy and rehabilitation of people with movement disorders makes recommendations for future research and discusses the use of VR in the clinic. However, the potential for using these techniques in gait rehabilitation is to provide a more personalized approach by simulate the experience of natural walking, while patients with neurological disorders are maintained localized in the real world. The goal of our work is to investigate how the human nervous system controls movement in health and neurodegenerative disease.

Outside testing of wearable robots for gait assistance shows a higher metabolic benefit than testing on treadmills

Most wearable robots that assist the gait of workers, soldiers, athletes, and hobbyists are developed towards a vision of outdoor, overground walking. However, so far, these devices have predominantly been tested indoors on laboratory treadmills. It is unclear whether treadmill-based laboratory tests are an accurate representation of overground ambulation outdoors with respect to essential outcomes such as the metabolic benefits of robotic assistance. In this study, we investigated the metabolic benefits of the Myosuit, a wearable robot that assists hip and knee extension during the stance phase of gait, for eight unimpaired participants during uphill walking trials in three settings: outside, on a self-paced treadmill with a virtual reality display, and on a standard treadmill at a fixed gait speed. The relative metabolic reduction with Myosuit assistance was most pronounced in the outside setting at - 10.6% and significantly larger than in the two treadmill settings (- 6.9%, p = 0.015 and - 6.2%, p = 0.008). This indicates that treadmill tests likely result in systematically low estimate for the true metabolic benefits of wearable robots during outside, overground walking. Hence, wearable robots should preferably be tested in an outdoor environment to obtain more representative-and ultimately more favorable-results with respect to the metabolic benefit of robotic gait assistance.

The Effects of Visual Backgrounds in the Virtual Environments on the Postural Stability of Standing

A photorealistic scene in a head mount display (HMD) is considered high fidelity and associated with postural stability similar to that in the real world, but the effects of visual background under different standing conditions have not been examined. Thirty-four healthy adults performed four standing (standardized, narrow, tandem and one-leg) tasks in three scenes with an HMD, while viewing one of three scenes: a real room (real scene, RS), a photorealistic scene (VrS) and a blank scene (BS). The effects of the visual scenes and standing tasks on sway parameters were analyzed. Romberg quotients (RQs) of the sway parameters were compared between RS and VrS with reference to BS to compare visual contribution to posture stability. Sway parameters were similar during all three scenes during the standardized and narrow standing tasks, but higher in VrS and BS conditions than in the RS condition during the tandem and one-leg standing tasks. The effects of visual scenes on postural stability showed a significant interaction with the standing tasks. The BS/VsR and BS/RS ratios were close to 1.0 for the standardized and narrow standing tasks, and the magnitude of increase was lower for BS/VsR than BS/RS during the tandem and one-leg standing tasks, indicating different levels of visual dependence. The effects of virtual scenes on postural stability were task-dependent. Adjusting the amount of visual stimuli and choosing tasks with higher postural demands may result in synergic effects, but the influence of visual environments should be examined with consideration of visual targeting.

Facial Expression-Based Experimental Analysis of Human Reactions and Psychological Comfort on Glass Structures in Buildings

For engineering applications, human comfort in the built environment depends on several objective aspects that can be mathematically controlled and limited to reference performance indicators. Typical examples include structural, energy and thermal issues, and others. Human reactions, however, are also sensitive to a multitude of aspects that can be associated with design concepts of the so-called “emotional architecture”, through which subjective feelings, nervous states and emotions of end-users are evoked by constructional details. The interactions of several objective and subjective parameters can make the “optimal” building design challenging, and this is especially the case for new technical concepts, constructional materials and techniques. In this paper, a remote experimental methodology is proposed to explore and quantify the prevailing human reactions and psychological comfort trends for building occupants, with a focus on end-users exposed to structural glass environments. Major advantages were taken from the use of virtual visual stimuli and facial expression automatic recognition analysis, and from the active support of 30 volunteers. As shown, while glass is often used in constructions, several intrinsic features (transparency, brittleness, etc.) are responsible for subjective feelings that can affect the overall psychological comfort of users. In this regard, the use of virtual built environments and facial expression analysis to quantify human reactions can represent an efficient system to support the building design process.

Opportunities and challenges of using augmented reality and heads-up display in orthopaedic surgery: A narrative review

BACKGROUND & AIM

Utilization of augmented reality (AR) and heads-up displays (HUD) to aid orthopaedic surgery has the potential to benefit surgeons and patients alike through improved accuracy, safety, and educational benefits. With the COVID-19 pandemic, the opportunity for adoption of novel technology is more relevant. The aims are to assess the technology available, to understand the current evidence regarding the benefit and to consider challenges to implementation in clinical practice.

METHODS & RESULTS

PRISMA guidelines were used to filter the literature. Of 1004 articles returned the following exclusion criteria were applied: 1) reviews/commentaries 2) unrelated to orthopaedic surgery 3) use of other AR wearables beyond visual aids leaving 42 papers for review.This review illustrates benefits including enhanced accuracy and reduced time of surgery, reduced radiation exposure and educational benefits.

CONCLUSION

Whilst there are obstacles to overcome, there are already reports of technology being used. As with all novel technologies, a greater understanding of the learning curve is crucial, in addition to shielding our patients from this learning curve. Improvements in usability and implementing surgeons' specific needs should increase uptake.

Touchscreen cognitive testing: Cross-species translation and co-clinical trials in neurodegenerative and neuropsychiatric disease

Translating results from pre-clinical animal studies to successful human clinical trials in neurodegenerative and neuropsychiatric disease presents a significant challenge. While this issue is clearly multifaceted, the lack of reproducibility and poor translational validity of many paradigms used to assess cognition in animal models are central contributors to this challenge. Computer-automated cognitive test batteries have the potential to substantially improve translation between pre-clinical studies and clinical trials by increasing both reproducibility and translational validity. Given the structured nature of data output, computer-automated tests also lend themselves to increased data sharing and other open science good practices. Over the past two decades, computer automated, touchscreen-based cognitive testing methods have been developed for non-human primate and rodent models. These automated methods lend themselves to increased standardization, hence reproducibility, and have become increasingly important for the elucidation of the neurobiological basis of cognition in animal models. More recently, there have been increased efforts to use these methods to enhance translational validity by developing task batteries that are nearly identical across different species via forward (i.e., translating animal tasks to humans) and reverse (i.e., translating human tasks to animals) translation. An additional benefit of the touchscreen approach is that a cross-species cognitive test battery makes it possible to implement co-clinical trials-an approach developed initially in cancer research-for novel treatments for neurodegenerative disorders. Co-clinical trials bring together pre-clinical and early clinical studies, which facilitates testing of novel treatments in mouse models with underlying genetic or other changes, and can help to stratify patients on the basis of genetic, molecular, or cognitive criteria. This approach can help to determine which patients should be enrolled in specific clinical trials and can facilitate repositioning and/or repurposing of previously approved drugs. This has the potential to mitigate the resources required to study treatment responses in large numbers of human patients.

Will virtual rehabilitation replace clinicians: a contemporary debate about technological versus human obsolescence

This article is inspired by a pseudo Oxford-style debate, which was held in Tel Aviv University, Israel at the International Conference on Virtual Rehabilitation (ICVR) 2019, which is the official conference of the International Society for Virtual Rehabilitation. The debate, between two 2-person teams with a moderator, was organized by the ICVR Program committee to address the question "Will virtual rehabilitation replace clinicians?" It brought together five academics with technical, research, and/or clinical backgrounds-Gerry Fluet, Tal Krasovsky, Anat Lubetzky, Philippe Archambault, W. Geoffrey Wright-to debate the pros and cons of using virtual reality (VR) and related technologies to help assess, diagnose, treat, and track recovery, and more specifically investigate the likelihood that advanced technology will ultimately replace human clinicians. Both teams were assigned a side to defend, whether it represented their own viewpoint or not, and to take whatever positions necessary to make a persuasive argument and win the debate. In this paper we present a recapitulation of the arguments presented by both sides, and further include an in-depth consideration of the question. We attempt to judiciously lay out a number of arguments that fall along a spectrum from moderate to extreme; the most extreme and/or indefensible positions are presented for rhetorical and demonstrative purposes. Although there may not be a clear answer today, this paper raises questions which are related to the basic nature of the rehabilitation profession, and to the current and potential role of technology within it.

Using Augmented Reality with Older Adults in the Community to Select Design Features for an Age-Friendly Park: A Pilot Study

Sedentary behavior is prevalent in older adults. Older adults often underutilize public parks for exercising because the parks do not support their needs and preferences. Engaging older adults on the redesign of parks may help promote active lifestyles. The objectives of this pilot study were to evaluate (1) the effects of wearing augmented reality (AR) and virtual reality (VR) glasses on balance; (2) the effects of different virtual walls separating the walking trail from the roadway on older adults' gait, and (3) the preferences of the participants regarding wall design and other features. The participants were ten older adults (68 ± 5 years) who lived within two miles from the park. Balance and gait were assessed using a force plate and an instrumented mat. It was feasible to use AR with older adults in the park to evaluate features for redesign. Motion sickness was not an issue when using AR glasses, but balance was affected when wearing VR goggles. The area of postural sway increased approximately 25% when wearing AR glasses, and it increased by close to 70% when wearing VR goggles compared to no glasses. This difference is clinically relevant; however, we did not have enough power to identify the differences as statistically significant because of the small sample size and large variability. Different walls did not significantly affect the participants' gait either because they did not alter the way they walked or because the holograms were insufficiently realistic to cause changes. The participants preferred a transparent wall rather than tall or short solid walls to separate the park from the roadway.

Walking Gait Mechanics and Gaze Fixation in Individuals With Chronic Ankle Instability

CONTEXT

Many individuals who suffer a lateral ankle sprain will develop chronic ankle instability (CAI). Individuals with CAI demonstrate kinematic differences in walking gait, as well as somatosensory alterations compared with healthy individuals. However, the role of vision during walking gait in this population remains unclear.

OBJECTIVE

To evaluate ankle kinematics, gaze deviations, and gaze velocity between participants with CAI and healthy controls while walking on a treadmill during 3 separate visual conditions (no target, fixed target, and moving target).

DESIGN

Case-control study.

SETTING

Laboratory. Patients (or Other Participants): Ten CAI participants and 10 healthy matched controls participated.

MAIN OUTCOME MEASURES

Ankle sagittal and frontal plane kinematics were analyzed for the entire gait cycle. Average and standard deviation (SD) for gaze deviation and gaze velocity were calculated in the horizontal (X) and vertical (Y) planes.

RESULTS

No significant differences were found between groups for either ankle kinematics or gaze variables; however, large effect sizes were found in the no target condition for average deviation of X (healthy 0.05 [0.02], CAI 0.12 [0.11]). Moderate effect sizes were identified in the no target condition for SD of Y (healthy 0.04 [0.03], CAI 0.11 [0.15]) and the moving target condition for average velocity of X (healthy 1.56 [0.73], CAI 2.27 [1.15]) and Y (healthy 1.07 [0.51], CAI 1.47 [0.52]).

CONCLUSIONS

Although no significant differences were found between groups, it is possible that the role of vision in individuals with CAI may be altered with a more difficult task.

Virtual Reality, Augmented Reality, Gamification, and Telerehabilitation: Psychological Impact on Orthopedic Patients' Rehabilitation

Background: Remote virtual rehabilitation aroused growing interest in the last decades, and its role has gained importance following the recent spread of COVID19 pandemic. The advantages of virtual reality (VR), augmented reality (AR), gamification, and telerehabilitation have been demonstrated in several medical fields. In this review, we searched the literature for studies using these technologies for orthopedic rehabilitation and analyzed studies’ quality, type and field of rehabilitation, patients’ characteristics, and outcomes to describe the state of the art of VR, AR, gamification, and telerehabilitation for orthopedic rehabilitation. Methods: A comprehensive search on PubMed, Medline, Cochrane, CINAHL, and Embase databases was conducted. This review was performed according to PRISMA guidelines. Studies published between 2015 and 2020 about remote virtual rehabilitations for orthopedic patients were selected. The Methodological Index for Non-Randomized Studies (MINORS) and Cochrane Risk-of-Bias assessment tool were used for quality assessment. Results: 24 studies (9 randomized controlled trials (RCTs) and 15 non-randomized studies) and 2472 patients were included. Studies mainly concern telerehabilitation (56%), and to a lesser extent VR (28%), AR (28%), and gamification (16%). Remote virtual technologies were used following knee and hip arthroplasty. The majority of included patients were between 40 and 60 years old and had a university degree. Remote virtual rehabilitation was not inferior to face-to-face therapy, and physical improvements were demonstrated by increased clinical scores. Orthopedic virtual remote rehabilitation decreased costs related to transports, hospitalizations, and readmissions. Conclusion: The heterogeneity of included studies prevented a meta-analysis of their results. Age and social context influence adaptability to technology, and this can modify compliance to treatment and outcomes. A good relationship between patient and physiotherapist is essential for treatment compliance and new technologies are useful to maintain clinical interactions remotely. Remote virtual technologies allow the delivery of high-quality care at reduced costs. This is a necessity given the growing demand for orthopedic rehabilitation and increasing costs related to it. Future studies need to develop specific and objective methods to evaluate the clinical quality of new technologies and definitively demonstrate advantages of VR, AR, gamification, and telerehabilitation compared to face-to face orthopedic rehabilitation.

Biomechanical effects following footstrike pattern modification using wearable sensors

OBJECTIVES

This study sought to examine the biomechanical effects of an in-field sensor-based gait retraining program targeting footstrike pattern modification during level running, uphill running and downhill running.

DESIGN

Quasi-experimental design.

METHODS

Sixteen habitual rearfoot strikers were recruited. All participants underwent a baseline evaluation on an instrumented treadmill at their preferred running speeds on three slope settings. Participants were then instructed to modify their footstrike pattern from rearfoot to non-rearfoot strike with real-time audio biofeedback in an 8-session in-field gait retraining program. A reassessment was conducted to evaluate the post-training biomechanical effects. Footstrike pattern, footstrike angle, vertical instantaneous loading rate (VILR), stride length, cadence, and knee flexion angle at initial contact were measured and compared.

RESULTS

No significant interaction was found between training and slope conditions for all tested variables. Significant main effects were observed for gait retraining (p-values≤0.02) and slopes (p-values≤0.01). After gait retraining, 75% of the participants modified their footstrike pattern during level running, but effects of footstrike pattern modification were inconsistent between slopes. During level running, participants exhibited a smaller footstrike angle (p≤0.01), reduced VILR (p≤0.01) and a larger knee flexion angle (p=0.01). Similar effects were found during uphill running, together with a shorter stride length (p=0.01) and an increased cadence (p≤0.01). However, during downhill running, no significant change in VILR was found (p=0.16), despite differences found in other biomechanical measurements (p-values=0.02-0.05).

CONCLUSION

An 8-session in-field gait retraining program was effective in modifying footstrike pattern among runners, but discrepancies in VILR, stride length and cadence were found between slope conditions.