Designing informed game-based rehabilitation tasks leveraging advances in virtual reality

Effectiveness of Immersive Virtual Reality-Based Hand Rehabilitation Games for Improving Hand Motor Functions in Subacute Stroke Patients

Stroke rehabilitation faces challenges in attaining enduring improvements in hand motor function and is frequently constrained by interventional limitations. This research aims to present an innovative approach to the integration of cognitive engagement within visual feedback incorporated into fully immersive virtual reality (VR) based games to achieve enduring improvements. These innovative aspects of interaction provide more functional advantages beyond motivation to efficiently execute repeatedly hand motor tasks. The effectiveness of virtual reality games incorporated with innovative aspects has been investigated for improvements in hand motor functions. A randomized controlled trial was conducted, a total of (n=56) subacute stroke patients were assessed for eligibility and (n=52) patients fulfilled the inclusion criteria. (n=26) patients were assigned to the experimental group and (n=26) patients were assigned to the control group. VR intervention involves four VR based games, developed based on hand movements including flexion/extension, close/open, supination/pronation and pinch. All patients got therapy of 24 sessions, lasting 4 days/week for a total of 6 weeks. Five clinical outcome measures were Fugl- Meyer Assessment-Upper Extremity, Action Research Arm Test, Box and Block Test, Modified Barthel Index, and Stroke-Specific Quality of Life were assessed to evaluate patients' performance. Results revealed that after therapy there was significant improvement between the groups (p<0.05) and within groups (p<0.05) in all assessment weeks in all clinical outcome measures however, improvement was observed significantly greater in the experimental group due to fully immersive VR-based games. Results indicated that cognitive engagement within visual feedback incorporated in VR-based hand games effectively improved hand motor functions.

Effectiveness of Virtual Reality-Based Rehabilitation Interventions in Improving Postoperative Outcomes for Orthopedic Surgery Patients

PURPOSE OF REVIEW

The surge in orthopedic surgeries strains the US healthcare system, necessitating innovative rehabilitation solutions. This review examines the potential of virtual reality (VR)-based interventions for orthopedic rehabilitation.

RECENT FINDINGS

The effectiveness of VR-based interventions in orthopedic surgery patients is scrutinized. While some studies suggest better patient-reported outcomes and satisfaction, mixed results emerge from others, demonstrating comparable or varied results compared to traditional rehabilitation. The underlying mechanisms of VR-based rehabilitation are elucidated, showing its positive impact on proprioception, pain management, agency, and balance. Challenges of unfamiliarity, patient engagement, and drop-out rates are identified, emphasizing the need for tailored approaches. VR technology's immersive environments and multisensory experiences offer a novel approach to addressing functional deficits and pain post-surgery. The conclusion drawn is that VR-based rehabilitation complements rather than replaces conventional methods, potentially aiding in pain reduction and functional improvement. VR-based rehabilitation holds promise for enhancing orthopedic surgery outcomes, presenting a dynamic approach to recovery. Its potential to reshape healthcare delivery and reimbursement structures underscores its significance in modern healthcare. Overall, VR-based rehabilitation offers a promising avenue for optimizing postoperative recovery in orthopedic surgery patients.

Virtual reality applications based on instrumental activities of daily living (iADLs) for cognitive intervention in older adults: a systematic review

BACKGROUND

In recent years, the use of virtual reality (VR) as a complementary intervention in treating cognitive impairment has significantly increased. VR applications based on instrumental activities of daily living (iADL-VR) could offer a promising approach with greater ecological validity for intervention in groups with cognitive impairments. However, the effectiveness of this approach is still debated.

OBJECTIVE

This systematic review aims to synthesize the effects of iADL-VR interventions to rehabilitate, train, or stimulate cognitive functions in healthy adults and people with mild cognitive impairment (MCI) and different types of dementia.

METHODS

A systematic search was performed in the Scopus, PubMed, IEEE Xplore, Web of Science, and APA PsycNet databases until September 2022 and repeated in April 2023. The selected studies met the search terms, were peer-reviewed, included an iADL-VR intervention, and were written in English. Descriptive, qualitative studies, reviews, cognitive assessment, non-intervention studies, those unrelated to VR or iADL, those focused on motor aspects, and non-degenerative disorders were excluded. The PEDro scale was used to assess the methodological quality of the controlled studies. To present and synthesize the results, we organized the extracted data into three tables, including PEDro scores, participant characteristics, and study characteristics.

RESULTS

Nineteen studies that met the inclusion and exclusion criteria were included. The total sample reached 590 participants, mostly women (72.67%). Approximately 30% were diagnosed with Alzheimer's disease or dementia, and 20% had mild cognitive impairment. Variables such as authors and year of publication, study design, type of intervention and VR applied, duration of the intervention, main findings, and conclusions were extracted. Regarding demographic characteristics, the sample size, age, sex, years of education, neurological diagnosis, dropouts, and the city and country where the intervention took place were recorded. Almost all studies showed improvements in some or all the outcomes after the intervention, generally greater in the iADL-VR group than in the control group.

CONCLUSION

iADL-VR interventions could be beneficial in improving the performance of cognitive functions in older adults and people with MCI and different types of dementia. The ecological component of these tasks makes them very suitable for transferring what has been learned to the real world. However, such transfer needs to be confirmed by further studies with larger and more homogeneous samples and longer follow-up periods. This review had no primary funding source and was registered with PROSPERO under registration ID: 375166.

Application of Virtual Reality-Assisted Exergaming on the Rehabilitation of Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

BACKGROUND

Rehabilitation programs for children with cerebral palsy (CP) aim to improve their motor and cognitive skills through repeated and progressively challenging exercises. However, these exercises can be tedious and demotivating, which can affect the effectiveness and feasibility of the programs. To overcome this problem, virtual reality VR-assisted exergaming has emerged as a novel modality of physiotherapy that combines fun and motivation with physical activity. VR exergaming allows children with CP to perform complex movements in a secure and immersive environment, where they can interact with virtual objects and scenarios. This enhances their active engagement and learning, as well as their self-confidence and enjoyment. We aim to provide a comprehensive overview of the current state of research on VR exergaming for CP rehabilitation. The specific objectives are: To identify and describe the existing studies that have investigated the effects of VR exergaming on motor function and participation outcomes in children with CP. In addition, we aim to identify and discuss the main gaps, challenges, and limitations in the current research on VR exergaming for CP rehabilitation. Finally, we aim to provide recommendations and suggestions for future research and practice in this field.

METHODS

In June 2023, we conducted a systematic search on Scopus, Web of Science, PubMed, Cochrane, and Embase for randomized trials and cohort studies that applied VR-assisted exergaming to rehabilitating patients with CP. The inclusion criteria encompassed the following: (1) Randomized controlled trials (RCTs) and cohort studies involving the rehabilitation of children with CP; (2) the application of VR-based exergaming on the rehabilitation; (3) in comparison with conventional rehabilitation/usual care. The quality of the selected RCTs was evaluated using Cochrane's tool for risk of bias assessment bias includes. Whereas the quality of cohort studies was assessed using the National Institutes of Health (NIH) tool.

RESULTS

The systematic search of databases retrieved a total of 2576 studies. After removing 863 duplicates, 1713 studies underwent title and abstract screening, and 68 studies were then selected as eligible for full-text screening. Finally, 45 studies were involved in this review (n = 1580), and 24 of those were included in the quantitative analysis. The majority of the included RCTs had a low risk of bias regarding study reporting, participants' attrition, and generating a random sequence. Nearly half of the RCTs ensured good blinding of outcomes assessors. However, almost all the RCTs were unclear regarding the blinding of the participants and the study personnel. The 2020 retrospective cohort study conducted at Samsung Changwon Hospital, investigating the effects of virtual reality-based rehabilitation on upper extremity function in children with cerebral palsy, demonstrated fair quality in its methodology and findings. VR-assisted exergaming was more effective than conventional physiotherapy in improving the Gross Motor Function Measurement (GMFM)-88 score (MD = 0.81; 95% CI [0.15, 1.47], p-value = 0.02) and the GMFM walking and standing dimensions (MD = 1.45; 95% CI [0.48, 2.24], p-value = 0.003 and MD = 3.15; 95% CI [0.87, 5.42], p-value = 0.007), respectively. The mobility and cognitive domains of the Pediatric Evaluation of Disability Inventory score (MD = 1.32; 95% CI [1.11, 1.52], p-value < 0.001) and (MD = 0.81; 95% CI [0.50, 1.13], p-value < 0.0001) were also improved. The Canadian Occupational Performance Measure performance domain (MD = 1.30; 95% CI [1.04, 1.56], p-value < 0.001), the WeeFunctional Independence Measure total score (MD = 6.67; 95% CI [6.36, 6.99], p-value < 0.0001), and the Melbourne Assessment of Unilateral Upper Limb Function-2 score (p-value < 0.001) improved as well. This new intervention is similarly beneficial as conventional therapy in improving other efficacy measures.

CONCLUSIONS

Our findings suggest that VR-assisted exergaming may have some advantages over conventional rehabilitation in improving CP children's functioning and performance in daily life activities, upper and lower limb mobility, and cognition. VR-assisted exergaming seems to be as effective as conventional physiotherapy in the other studied function measures. With its potential efficacy, better feasibility, no reported side effects, and entertaining experience, VR-assisted exergaming may be a viable complementary approach to conventional physiotherapy in rehabilitating children with CP.

The Application of Fully Immersive Virtual Reality on Reminiscence Interventions for Older Adults: Scoping Review

BACKGROUND

The increasing number of older adults with mental, behavioral, and memory challenges presents significant public health concerns. Reminiscence is one type of nonpharmacological intervention that can effectively evoke memories, stimulate mental activities, and improve psychological well-being in older adults through a series of discussions on previous experiences. Fully immersive virtual reality (FIVR) may be a useful tool for reminiscence interventions because it uses realistic virtual environments connected to a person's significant past stories.

OBJECTIVE

This review aims to examine empirical evidence regarding the application of FIVR in reminiscence interventions, its usability and acceptability, and its effectiveness in assisting the intervention to achieve optimal outcomes.

METHODS

We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach for scoping reviews. The PubMed, PsycINFO, Embase, CINAHL, Web of Science, ACM, and IEEE Xplore electronic databases were used for the search. We included peer-reviewed studies that used FIVR as an assistive tool for reminiscence interventions; were published between January 1, 2000, and August 1, 2022; reported empirical research; involved older adults as participants; and addressed health- and behavior-related outcomes or the feasibility and usability of FIVR. We used Endnote X9 to organize the search results and Microsoft Excel for data extraction and synthesis.

RESULTS

Of the 806 articles collected from the databases and other resources, 11 were identified. Most of the studies involved participants aged between 70 and 90 years. Only 1 study did not involve those with cognitive impairments, whereas 3 specifically targeted people living with dementia. The results indicated that FIVR reminiscence interventions enhanced engagement and reduced fatigue. Although some studies have observed positive effects on anxiety, apathy, depression, cognitive functions, and caregiver burden reduction, these findings were inconsistent across other research. In addition, FIVR showed overall usability and acceptability with manageable side effects among older adults across various health conditions during reminiscence sessions. However, 1 study reported adverse feelings among participants, triggered by unpleasant memories evoked by the virtual reality content.

CONCLUSIONS

The role of FIVR in reminiscence interventions remains nascent, with limited studies evaluating its impacts on older adults. Many of the reviewed studies had notable limitations: small sample sizes, absence of rigorous research design, limited assessment of long-term effects, lack of measures for health and behavior outcomes, and quality of life. Beyond these limitations, this review identified a list of future research directions in 6 categories. On the basis of the review findings, we provide practical recommendations to enhance FIVR reminiscence interventions, covering topics such as virtual reality content, device choice, intervention types, and the role and responsibility of facilitators.

The Impact of Virtual Reality (VR) Gaming and Casual/Social Gaming on the Quality of Life, Depression, and Dialysis Tolerance in Patients With Chronic Kidney Disease: A Narrative Review

This comprehensive narrative review aims to investigate the impact of virtual reality (VR) and social gaming on the quality of life, depression, and dialysis tolerance in patients with chronic kidney disease (CKD), a growing global health concern affecting the quality of life and increasing mortality rates. Through a combination of exercise and video games, exergaming, and digital game therapy (DGT), sedentary risks can be mitigated and therapy adherence enhanced. Despite potential side effects such as exhaustion and nausea, research indicates that virtual therapeutic games improve motivation and dialysis tolerance, and even reduce brain activity in pain-associated regions during procedures. These methods are superior to traditional distraction techniques like music, movies, and toys. Exergaming, social gaming, and VR gaming can improve various health factors including depressive symptoms, functional capacity, muscle strength, fatigue, physical activity, mental health, motivation, engagement, cognition, and overall quality of life for CKD patients. Representing a novel approach to CKD management, these interventions promote physical activity, cognitive stimulation, and social interaction. Continued research and innovation will facilitate the integration of VR-based therapies into routine CKD care.

Effect of Physiotherapy Treatment with Immersive Virtual Reality in Subjects with Stroke: A Protocol for a Randomized Controlled Trial

BACKGROUND

Many stroke survivors suffer from sensorimotor deficits, especially balance impairments. The purpose of this trial is to investigate whether the designed Immersive Virtual Reality training program is better in the short term (15 sessions) and in the medium term (30 sessions) than physiotherapy training with Bayouk, Boucher and Leroux exercises, with respect to static balance in sitting and standing, dynamic balance and quality of life in patients with balance impairment in stroke survivors.

METHODS

This study is a randomized controlled trial with two treatment arms and evaluators blinded, and a functionality treatment group in combination with specific balance exercise training according to Bayouk, Boucher and Leroux (control group) or a balanced treatment using Immersive VR. The primary outcome will be static, Dynamic balance and gait measured by Bestest Assessment Score (BESTest), Berg Scale (BBS), Pass Scale (PASS) and Time Up and Go test (TUG). The secondary outcome will be the stroke-associated quality of life using the Stroke Quality of Life Scale (ECVI-38).

CONCLUSIONS

The results of this study may add new insights into how to address balance using Immersive Virtual Reality after a stroke. If the new training approach proves effective, the results may provide insight into how to design more comprehensive protocols in the future for people with balance impairments after stroke.

Virtual Reality-Based Rehabilitation to Restore Motor Function in People With Amputation: A Systematic Literature Review

ABSTRACT

Virtual reality is an emerging technology with accumulating research and clinical evidence in the field of physical rehabilitation. This study aimed to systematically identify and examine the effects of virtual reality on motor function outcomes in patients with amputation to inform clinical decision making on amputation rehabilitation and inform further research endeavors. Five databases were searched, including PubMed, CINAHL, PsycINFO, Embase, and Scopus. After screening for 1052 records, 10 clinical studies were included in this review: four randomized controlled trials, three pre-post single-arm studies, and three case studies; all studies had fair to good methodological quality. Seven studies were for lower extremity amputation, and three were for upper extremity amputation. Results reveal the positive effects of virtual reality on improving motor function in prosthesis training, including balance, gait, and upper extremity outcomes. Participants also report enjoyment during virtual reality intervention as measured by subjective experience. However, it is unclear whether virtual reality can induce better therapeutic outcomes than conventional rehabilitation, given the limited number of controlled studies and conflicting results reported in the included studies. More properly designed randomized controlled trials with adequately powered sample sizes are warranted to elucidate the benefits of virtual reality-based rehabilitation in the amputation population.

Comparison of immersive and non-immersive virtual reality for upper extremity functional recovery in patients with stroke: a systematic review and network meta-analysis

OBJECTIVE

This systematic review aimed to compare the effects of immersive and non-immersive virtual reality on upper extremity function in stroke survivors by employing a network meta-analysis approach.

DATA SOURCES

MEDLINE, Embase, CINAHL Plus, APA PsycINFO, and Scopus were searched. Virtual reality was used for upper extremity rehabilitation; dose-matched conventional rehabilitation was used for comparison. Fugl-Meyer Assessment was used to assess upper extremity function. Searches were limited to English language randomized controlled trials.

METHODS

Two independent reviewers conducted study selection, data extraction, and quality assessment. Methodological quality was assessed using the Physiotherapy Evidence Database scale. A random-effects frequentist network meta-analysis was conducted by assuming a common random-effects standard deviation for all comparisons in the network.

RESULTS

Twenty randomized controlled trials with 813 participants were included, with each study evaluated as good quality. Immersive virtual reality systems were most effective at improving upper extremity function, followed by non-immersive virtual reality systems, then non-immersive gaming consoles of Microsoft Kinect and Nintendo Wii. Conventional rehabilitation was least effective. Immersive virtual reality was estimated to induce 1.39 (95% confidence interval (CI): 0.25, 2.53) and 1.38 (95% CI: 0.55, 2.20) standard mean differences of improvements in upper extremity function, compared to Nintendo Wii intervention and conventional rehabilitation, respectively.

CONCLUSION

This systematic review and network meta-analysis highlights the superior effects of immersive virtual reality to non-immersive virtual reality systems and gaming consoles on upper extremity motor recovery.

Influence of Hand Tracking in Immersive Virtual Reality for Memory Assessment

Few works analyze the parameters inherent to immersive virtual reality (IVR) in applications for memory evaluation. Specifically, hand tracking adds to the immersion of the system, placing the user in the first person with full awareness of the position of their hands. Thus, this work addresses the influence of hand tracking in memory assessment with IVR systems. For this, an application based on activities of daily living was developed, where the user must remember the location of the elements. The data collected by the application are the accuracy of the answers and the response time; the participants are 20 healthy subjects who pass the MoCA test with an age range between 18 to 60 years of age; the application was evaluated with classic controllers and with the hand tracking of the Oculus Quest 2. After the experimentation, the participants carried out presence (PQ), usability (UMUX), and satisfaction (USEQ) tests. The results indicate no difference with statistical significance between both experiments; controller experiments have 7.08% higher accuracy and 0.27 ys. faster response time. Contrary to expectations, presence was 1.3% lower for hand tracking, and usability (0.18%) and satisfaction (1.43%) had similar results. The findings indicate no evidence to determine better conditions in the evaluation of memory in this case of IVR with hand tracking.

PedaleoVR: Usability study of a virtual reality application for cycling exercise in patients with lower limb disorders and elderly people

Achieving adherence to physical exercise training is essential in elders and adults with neurological disorders. Immersive technologies are seeing wide adoption among new neurorehabilitation therapies, as they provide a highly effective motivational and stimulating component. The aim of this study is to verify whether the developed virtual reality system for pedaling exercise is accepted and could be safety, useful and motivating for these populations. A feasibility study was conducted with patients with neuromotor disorders and elderly people from Lescer Clinic and the residential group Albertia, respectively. All the participants performed a pedaling exercise session with virtual reality platform. Then, the Intrinsic Motivation Inventory, the System Usability Scale (SUS), Credibility and Expectancy Questionnaire, were assessed in the group of 20 adults (mean age = 61.1; standard deviation = 12.617, 15 males and 5 females) with lower limb disorders. While the Simulator Sickness Questionnaire, Presence Questionnaire, Game user Experience Satisfaction Scale and SUS were assessed in the group of 18 elders (mean age = 85.16; standard deviation = 5.93, 5 males and 13 females). In light of the outcomes, PedaleoVR is considered to be a credible, usable and motivational tool towards adults with neuromotor disorders to perform cycling exercise, and therefore its usage could contribute to adherence to lower limb training activities. Moreover, PedaleoVR does not generate negative effects related to cybersickness while the sensation of presence and the degree of satisfaction generated have been positively evaluated by the geriatric population. This trial has been registered at ClinicalTrials.gov under the identifier: NCT05162040, Dec 2021.

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

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

Fully Immersive Virtual Reality Game-Based Training for an Adolescent with Spastic Diplegic Cerebral Palsy: A Case Report

BACKGROUND

Recently, virtual reality-based training (VR-based training) is receiving attention as greater emphasis is placed on the importance of interest and motivation in participation. However, studies investigating the effects of fully immersive VR-based training are insufficient.

CASE PRESENTATION

We report a case of using a fully immersive VR game-based training in a patient with cerebral palsy. A 15-year-old girl was diagnosed with spastic diplegia cerebral palsy Gross Motor Function Classification System level II. A six-week intervention (18 sessions) phase was performed with one fully immersive VR game using PlayStation^®VR in three sessions per week. After 18 sessions of training, the scores on the gross motor function measure-88 (Gross Motor Function Measure-88-GMFM-88), pediatric balance scale (PBS), timed up and go test (TUG), functional gait assessment (FGA), and 10 m walking test (10MWT) were improved: GMFM-88, 91.56 points (9.31 points increase); PBS, 45 points (6 points increase); TUG, 8.23 s (6.9 s decrease); FGA, 11 points (3 points increase); the 10 MWT, 5.27 s (6.59 s decrease).

CONCLUSIONS

This study found that a fully immersive VR game-based training using PlayStation^®VR may be an effective intervention for GMFCS level II adolescent, leading to some improvement of motor function, balance and gait skills in adolescents with cerebral palsy.

Feasibility and Effects of an Immersive Virtual Reality Exergame Program on Physical Functions in Institutionalized Older Adults: A Randomized Clinical Trial

One of the pillars which underpins active aging is found in the performance of physical activity. While adherence to physical activity programs has traditionally been low in older people, immersive virtual reality (IVR) could provide an alternative and complementary training mode. A randomized clinical trial was conducted to explore the feasibility and effects of a 10-week IVR exergame program on physical functions of 24 institutionalized older adults who were allocated to an experimental group (EG n = 13; 85.08 ± 8.48 years) and control group (CG n = 11; 84.82 ± 8.10 years). The IVR intervention was feasible, with no adverse effects being reported (no Simulator Sickness Questionnaire symptoms; low negative experience scores on the Game Experience Questionnaire < 0.34/4), no dropouts, high adherence, and good post-gaming usability (System Usability Scale > 73.96%). The EG showed significant improvements: Tinetti scores for balance (1.84 ± 1.06; p < 0.001), gait (1.00 ± 1.08; p < 0.001), total score (2.84 ± 1.67; p < 0.001), and handgrip (4.96 ± 4.22; p < 0.001) (pre−post assessment). The CG showed significantly worsened compared to the EG: Five times sit-to-stand test, Tinetti scores for balance, gait, and total score, and the Timed Up and Go test total score (post-assessment). The findings show that the IVR intervention is a feasible method to approach a personalized exercise program and an effective way by which to improve physical function in the target population.

A novel immersive virtual reality environment for the motor rehabilitation of stroke patients: A feasibility study

We designed and implemented an immersive virtual reality (VR) environment for upper limb rehabilitation, which possesses several notable features. First, by exploiting modern computer graphics its can present a variety of scenarios that make the rehabilitation routines challenging yet enjoyable for patients, thus enhancing their adherence to the therapy. Second, immersion in a virtual 3D space allows the patients to execute tasks that are closely related to everyday gestures, thus enhancing the transfer of the acquired motor skills to real-life routines. Third, in addition to the VR environment, we also developed a client app running on a PC that allows to monitor in real-time and remotely the patients’ routines thus paving the way for telerehabilitation scenarios. Here, we report the results of a feasibility study in a cohort of 16 stroke patients. All our patients showed a high degree of comfort in our immersive VR system and they reported very high scores of ownership and agency in embodiment and satisfaction questionnaires. Furthermore, and notably, we found that behavioral performances in our VR tasks correlated with the patients’ clinical scores (Fugl-Meyer scale) and they could thus be used to assess improvements during the rehabilitation program. While further studies are needed, our results clearly support the feasibility and effectiveness of VR-based motor rehabilitation processes.

Rehabilitation efficacy comparison of virtual reality technology and computer-assisted cognitive rehabilitation in patients with post-stroke cognitive impairment: A network meta-analysis

OBJECTIVE

Virtual reality (VR) and computer-assisted cognitive rehabilitation (CACR) are two emerging rehabilitation therapies for stroke patients. The aim of this study was to compare the rehabilitation efficacy of these two treatments for patients with post-stroke cognitive impairment (PSCI).

METHODS

A network search of Embase, Web of Science, PubMed, Cochrane Library, VIP, WanFang Data, and CNKI databases was performed from their inception to February 2022 for screening randomized controlled trials related to VR and CACR in the treatment of PSCI. The quality of the included studies was assessed using the Cochrane risk bias assessment tool. The primary outcomes of the included studies contained at least one of the following clinical outcome measures: Mini-mental state examination (MMSE) or Montreal Cognitive Assessment (MoCA). After screening the literature, assessing the quality and extracting the data, a network meta-analysis was performed with STATA software.

RESULTS

A total of 21 randomized controlled trials were included, including 1,047 patients. The results of network meta-analysis showed that under MMSE index, VR group (p = 0.067) and CACR group (p = 0.054) tended to be superior to CT group, but it was not significant. Both the VR (p = 0.024) and CACR (p < 0.001) groups had significantly better outcomes compared to the conventional therapy group in terms of MoCA. The ranking results under both indicators showed that CACR had the best treatment effect, followed by VR.

CONCLUSION

In general, VR and CACR have superior efficacy compared with conventional therapy, in which CACR may be the best treatment option.

Effects of an Eye-Tracking Linkage Attention Training System on Cognitive Function Compared to Conventional Computerized Cognitive Training System in Patients with Stroke

Objective: The purpose of the study was to investigate the effects of an eye-tracking linkage attention training system on cognitive function compared to a conventional computerized cognitive training system in stroke patients with cognitive impairment. Methods: This retrospective study was enrolled 40 stroke patients who received cognitive rehabilitation. The intervention consisted of 30 sessions and 30 min per session. Before and after the intervention, we assessed cognitive functions by Mini-Mental State Examination (MMSE-K) and activities of daily living by Modified Barthel Index (K-MBI) and administered a computerized neuropsychological test (CNT). Results: In both groups, there were significant improvements in MMSE-K and K-MBI (p < 0.05). In the visual and auditory attention test of the CNT, the eye-tracking linkage attention training group was significantly improved after intervention (p < 0.05). However, there were no significant differences in the conventional computerized cognitive training group. In addition, there were significant improvements in all memory tests of the CNT in the eye-tracking linkage attention training group. However, in the conventional computerized cognitive training group, there were significant improvements in some memory tests of the CNT. Conclusions: The training of poststroke cognitive impairment patients using an eye-tracking linkage attention training system may improve visuospatial attention and may be helpful for the improvement of short-term memory and independent performances in daily life activities.

Effects of virtual reality intervention on neural plasticity in stroke rehabilitation: a systematic review

OBJECTIVE

To systematically review and examine the current literature regarding the effects of Virtual Reality (VR)-based rehabilitation on neural plasticity changes in stroke survivors.

DATA SOURCES

Six bioscience and engineering databases were searched, including Medline via Ebsco, Embase, PsycINFO, IEEE Explore, Cumulative Index of Nursing and Allied Health, and Scopus.

STUDY SELECTION

Studies reporting on the pre-post assessment of a VR intervention with neural plasticity measures published between 2000-2021 were included.

DATA EXTRACTION

Two independent reviewers conducted study selection, data extraction and quality assessment. Methodological quality of controlled trials was assessed using the Physiotherapy Evidence Database scale. Risk of bias of pre-post intervention and case studies was evaluated using the National Institutes of Health Quality Assessment Tool.

DATA SYNTHESIS

Twenty-seven studies (Total n=232) were included. Seven randomized controlled trials were rated as good quality while the two clinical controlled trials were moderate. Based on the risk of bias assessment, one pre-post study and one case study were graded as good quality, one pre-post study and one case study were poor, the other 14 studies were all at fair. After the VR intervention, main neurophysiological findings across studies include: (1) improved interhemispheric balance, (2) enhanced cortical connectivity, (3) increased cortical mapping of the affected limb muscles, (4) the improved neural plasticity measures were correlated to the enhanced behavior outcomes, (5) increased activation of regions in frontal cortex and (6) the mirror neuron system may be involved.

CONCLUSIONS

Virtual reality induced changes in neural plasticity for stroke survivors. Positive correlations between the neural plasticity changes and functional recovery elucidates the mechanisms of VR's therapeutic effects in stroke rehabilitation. This review prompts systematic understanding of the neurophysiological mechanisms of VR-based stroke rehabilitation and summarizes the emerging evidence for ongoing innovation of VR systems and application in stroke rehabilitation.

Effectiveness of virtual reality in children and young adults with cerebral palsy: a systematic review of randomized controlled trial

BACKGROUND

Cerebral palsy (CP) is one of the main causes of disability in childhood. Virtual reality (VR) has been used as a treatment option in this population, however its effectiveness is unclear.

OBJECTIVE

To evaluate the effectiveness of VR in patients with CP.

METHODS

We conducted electronic searches in EMBASE, MEDLINE, Cochrane library, PEDro, AMED, PsycoINFO, and LILACS databases and trial site registries such as ClinicalTrials.gov and ICTRP. We included randomized controlled trials that tested the use of VR alone or in combination with other interventions compared to more conventional rehabilitation or usual care in individuals with CP. The primary outcomes were upper and lower limb function, postural control, and balance. The secondary outcomes included global motor function, perception, cognition and spatial functions, motivation, motor learning, and adverse events. Two independent reviewers extracted and assessed included articles for risk of bias using the Cochrane risk of bias tool. We use a meta-analysis with random effect model whenever possible. We analyzed the quality of evidence using theGRADE approach.

RESULTS

We included 38 trials (pooled n = 1233 participants) in this review. There is very low quality of evidence that VR plus conventional rehabilitation is better than conventional rehabilitation for upper limb function. There is also very low quality evidence that VR alone is no better than conventional rehabilitation for upper and lower limb function. No adverse events were observed among the 10 trials that provided information on this outcome.

CONCLUSION

At present we have very limited to limited confidence in effect estimation for utilization of VR in this population. Future studies may change our confidence in results and effect estimates.

PROTOCOL REGISTRATION

PROSPERO CRD 42018102759.

The effect of virtual reality training on the daily participation of patients: A meta-analysis

BACKGROUND

Virtual reality (VR) training are regarded as promising new tools for rehabilitation, but the effect on patients' daily participation is controversial. This study aimed to evaluate the effect of virtual reality (VR) training on different types of patients' daily participation through a meta-analysis.

METHODS

The PubMed, Cochrane central register of controlled trials, Embase, and web science databases were searched for studies published through September 2020. Thirty-five randomized controlled trials of virtual reality (VR) training compared with conventional treatment, Other electronic rehabilitation systems, usual care for various types of patients were included. All of the studies were available in English. Standardized mean differences (SMD), 95 % confidence intervals (CI), publication bias, and heterogeneity were calculated.

RESULTS

The Virtual reality (VR) training group is better than the control group in daily participation improvement on all types of patients. There was a small, significant effect(p＜0.001; SMD = 0.25[95 %CI,0.14 to 0.36], I² = 0.00 %). Observing only the type of Stroke, the VR training group is still better than the control group in improving patients' daily participation (p＜0.001, SMD = 0.24[95 %CI, 0.11 to 0.37], I2 = 0.00 %). Using the cumulative Meta-analysis method to observe the included literature according to the timeline, Using the cumulative Meta-analysis method to observe the included literature according to the timeline, and it has only achieved positive results since 2015 (Nam-YoNg Lee 2015, p = 0.048, SMD = 0.22[95 %CI,0.00 to 0.44]). The heterogeneity of the studies was not detected, but there is obvious publication bias.

CONCLUSIONS

Because of controversy over obvious publication bias, we need to be cautious about the conclusion that VR is better than the control group in promoting the patient's daily participation.

Head-Mounted Display-Based Therapies for Adults Post-Stroke: A Systematic Review and Meta-Analysis

Immersive virtual reality techniques have been applied to the rehabilitation of patients after stroke, but evidence of its clinical effectiveness is scarce. The present review aims to find studies that evaluate the effects of immersive virtual reality (VR) therapies intended for motor function rehabilitation compared to conventional rehabilitation in people after stroke and make recommendations for future studies. Data from different databases were searched from inception until October 2020. Studies that investigated the effects of immersive VR interventions on post-stroke adult subjects via a head-mounted display (HMD) were included. These studies included a control group that received conventional therapy or another non-immersive VR intervention. The studies reported statistical data for the groups involved in at least the posttest as well as relevant outcomes measuring functional or motor recovery of either lower or upper limbs. Most of the studies found significant improvements in some outcomes after the intervention in favor of the virtual rehabilitation group. Although evidence is limited, immersive VR therapies constitute an interesting tool to improve motor learning when used in conjunction with traditional rehabilitation therapies, providing a non-pharmacological therapeutic pathway for people after stroke.

Virtual Reality-Assisted Cognitive Behavioral Therapy for Anxiety Disorders: A Systematic Review and Meta-Analysis

Objective: We aim to explore the effectiveness of virtual reality-assisted cognitive behavioral therapy (VRCBT) in the treatment of anxiety and depression in patients with anxiety disorders. We further compare the therapeutic effect of VRCBT with that of standard cognitive behavioral therapy (CBT), as well as investigate the long-term efficacy of VRCBT. Methods: As of March 3, 2020, a total of four databases (Web of Science, PubMed, PsycINFO, and Scopus) were retrieved, and two researchers independently conducted literature retrieval and research selection and performed data extraction. Methodological quality assessment was performed using the Cochrane risk of bias tool and Grading of Recommendation, Assessment, Development, and Evaluation tool (GRADE). Results: A total of 11 studies were included (n = 626; range, 25.3-43.8), and six randomized controlled trials were quantitatively analyzed. The main outcome was anxiety and depression, and the secondary outcome was the withdrawal rate and long-term effects. Meta-analysis showed that the therapeutic effect of VRCBT on anxiety was better than that of the waiting list group (WLG) (SMD = -0.92; 95% CI: -1.34, -0.50; p = 0.005, I ² = 66%, n = 276), while the therapeutic effect of VRCBT on anxiety was similar to that of standard CBT treatment (SMD = -0.26; 95% CI: -0.50, -0.01; p = 0.77, I ² = 0%, n = 150). We further found that the therapeutic effect of VRCBT on depression was better than that of the WLG (SMD = -1.29; 95% CI: -2.26, -0.32; p = 0.09, I ² = 58%, n = 74), while the effect of VRCBT was similar to that of standard CBT (SMD = -0.30; 95% CI: -0.67, -0.07; p = 0.39, I ² = 1%, n = 116). Of the five studies that reported withdrawal rates of patients during the VRCBT and CBT treatment process, the withdrawal rates of the VRCBT group and CBT group did not reach statistical significance (OR = 0.70, 1.48, p > 0.05); only two studies reported the long-term effectiveness of VRCBT in anxiety and depression on patients with anxiety disorders. Conclusion: VRCBT treatment has a specific positive effect on patients with anxiety disorders (anxiety and depression). Compared with standard CBT, similar therapeutic effects can be achieved in the treatment of anxiety disorders. However, limited randomized controlled trials were included, requiring that these results be treated with caution.

Upper limb rehabilitation interventions using virtual reality for people with multiple sclerosis: A systematic review

BACKGROUND

Research on Virtual Reality (VR) based motor rehabilitation for people with multiple sclerosis (MS) is rapidly growing in popularity, although few studies have focused on the upper limb (UL). The aims of this review were to investigate the effect of VR interventions on UL function in people with MS and determine if the type of VR intervention influences intervention effect.

METHOD

Five databases (IEEE Xplore, MEDLINE, ProQuest Central (Health & Medical Collection), Science Direct and Web of Science Core Collection) were searched using keywords that relating to MS, VR and UL.

RESULTS

Ten articles were included, six randomised controlled trials, three cohort studies and one pilot observational study. Both commercial and custom VR technologies were used in interventions, along with combination approaches using robotics, electrical stimulation and occupational therapy. Using the Nine Hole Peg Test, two studies found significant improvements within groups, one found that VR was more effective than another gaming approach. Significant improvements in other UL measures were in the Fugl-Meyer Assessment for the proximal arm; handgrip; perceived strength; Jebsen-Taylor Hand Function Test; Wolf Motor Function Test; active range of motion and trajectory measures after VR intervention. There were conflicting results regarding if VR was more effective than conventional approaches.

CONCLUSION

There is therefore some evidence that VR is effective in improving motor function in the UL, however, there is no clear consensus on which VR based approaches are the most effective, or the optimum intervention duration and intensity. Moreover, as many of the studies had non-immersive approaches it is hard to determine how effective immersion based approaches maybe in such specific context.

Effects of virtual reality training on occupational performance and self-efficacy of patients with stroke: a randomized controlled trial

Background

Virtual reality (VR) has been broadly applied in post-stroke rehabilitation. However, studies on occupational performance and self-efficacy as primary outcomes of stroke rehabilitation using VR are lacking. Thus, this study aims to investigate the effects of VR training on occupational performance and self-efficacy in patients with stroke.

Methods

This was an assessor-blinded, randomized controlled trial. Sixty participants with first-ever stroke (< 1-year onset) underwent rehabilitation in a single acute hospital. Participants were randomly assigned to either the VR group (n = 30) or control group (n = 30). Both groups received dose-matched conventional rehabilitation (i.e., 45 min, five times per week over 3 weeks). The VR group received additional 45-min VR training for five weekdays over 3 weeks. The primary outcome measures were the Canadian Occupational Performance Measure and Stroke Self-Efficacy Questionnaire. Secondary outcome measures included Modified Barthel Index, Fugl-Meyer Assessment-Upper Extremity, and Functional Test for the Hemiplegic Upper Extremity. The assessment was conducted at baseline and after the 3-week intervention.

Results

A total of 52 participants (86.7%) completed the trial. Significant between-group differences in Stroke Self-Efficacy Questionnaire (Median Difference = 8, P = 0.043) and Modified Barthel Index (Median Difference = 10, P = 0.030) were found; however, no significant between-group differences in Canadian Occupational Performance Measure, Fugl-Meyer Assessment-Upper Extremity, and Functional Test for the Hemiplegic Upper Extremity were noted. No serious adverse reactions related to the program were reported.

Conclusions

Additional VR training could help improve the self-efficacy and activities of daily living of patients with stroke; however, it was not superior to conventional training in the improvement of upper limb functions, occupational performance, and satisfaction. Nevertheless, VR could be integrated into conventional rehabilitation programs to enhance self-efficacy of patients after stroke.

Trial registration

This study was successfully registered under the title “Effects of virtual reality training on occupational performance and self-efficacy of patients with stroke” on October 13 2019 and could be located in https://www.chictr.org with the study identifier ChiCTR1900026550.

A survey of research trends in assistive technologies using information modelling techniques

BACKGROUND

Despite the rapid proliferation and emphasis on technology, the use of assistive technology among individuals with varying disabilities and age is different. This situation instigates the need for a systematic review to gain a realistic understanding of prominent issues, research trends and assistive technology applications with minimal bias.

OBJECTIVE

Identification of leading researchers and prominent publications in assistive technologies. Subsequently, semantic relation between qualitative and quantitative research literature on assistive technologies was explored to future research directions.

METHODS

A manual search across reputed research databases was done to find out relevant literature from January 2005 to April 2020. In this paper, latent semantic analysis (LSA) was done to develop an information model for achieving defined objectives.

RESULTS

A corpus of 367 research papers published during 2005-2020 was processed using LSA. Term frequency, inverse document frequency of high loading terms provided five major topic solutions. Marcia Scherer, Rory Cooper and Stefano Federici are most noticed authors in assistive technology research. "Smart Assistive Technologies" and "Wearable Technologies for Rehabilitation" came out as contemporary research trends within assistive technologies.

CONCLUSIONS

The manuscript concludes the fact that assistive technologies for rehabilitation are experiencing a transition from standalone mechanical devices towards smart, wearable and connected devices.Implications for RehabilitationCustomized assistive devices could be programmed for multiple uses.User data privacy and internet dependency of smart assistive technologies must be taken care of while designing smart assistive devices for rehabilitation.Fog devices could eliminate the latency issues associated with cloud-based rehabilitation services.

Telemedicine and Virtual Reality for Cognitive Rehabilitation: A Roadmap for the COVID-19 Pandemic

The current COVID-19 pandemic presents unprecedented new challenges to public health and medical care delivery. To control viral transmission, social distancing measures have been implemented all over the world, interrupting the access to routine medical care for many individuals with neurological diseases. Cognitive disorders are common in many neurological conditions, e.g., stroke, traumatic brain injury, Alzheimer's disease, and other types of dementia, Parkinson's disease and parkinsonian syndromes, and multiple sclerosis, and should be addressed by cognitive rehabilitation interventions. To be effective, cognitive rehabilitation programs must be intensive and prolonged over time; however, the current virus containment measures are hampering their implementation. Moreover, the reduced access to cognitive rehabilitation might worsen the relationship between the patient and the healthcare professional. Urgent measures to address issues connected to COVID-19 pandemic are, therefore, needed. Remote communication technologies are increasingly regarded as potential effective options to support health care interventions, including neurorehabilitation and cognitive rehabilitation. Among them, telemedicine, virtual reality, augmented reality, and serious games could be in the forefront of these efforts. We will briefly review current evidence-based recommendations on the efficacy of cognitive rehabilitation and offer a perspective on the role of tele- and virtual rehabilitation to achieve adequate cognitive stimulation in the era of social distancing related to COVID-19 pandemic. In particular, we will discuss issues related to their diffusion and propose a roadmap to address them. Methodological and technological improvements might lead to a paradigm shift to promote the delivery of cognitive rehabilitation to people with reduced mobility and in remote regions.

A comparative study of an assistive e-learning interface among students with and without visual and hearing impairments

Purpose: Using a human-computer interaction (HCI) approach, the present study proposes a new e-learning interface with interactional features for use by students with varying visual and hearing needs.Materials and method: Prototypes of these new features have been presented through several screens, including an interaction panel that allows for Button voice, Tab voice, Text voice, and sign language. The interactive features were evaluated by teachers and tested by students with and without visual and hearing impairments. Evaluation of the interface was conducted using a mixed methods design; student satisfaction with the features was measured quantitatively, while teacher perspectives regarding practical issues with implementation were explored through qualitative interviews.Results: The results indicate a high level of satisfaction towards the new interactional features in the suggested user interface among all students regardless of visual and hearing ability.Conclusion: The teachers involved in the study expressed the need for comprehensive cooperation from academic organisations through provision of required support, including technical, financial, and human resources.IMPLICATIONS FOR REHABILITATIONThe existing e-learning systems in higher educational organizations revealed the need to develop and implement instructional communication features based on technological components to support visual-and hearing-impaired students.The implementation of the accessible e-learning system is an important strategical approach to enhance flexible access to learning contents for all students who are unable to attend a traditional mode of learning.This type of accessible e-learning system, along with teachers' support, is needed to develop a more comprehensive understanding of the self-management of the student's learning process; giving students the opportunity to study according to their individual abilities, schedules and locations.The integration of appropriate visual and hearing assistive technology (AT) and its related applications, embedded within the educational technology infrastructure, are important resources to enhance the educational outcomes for visual- and hearingimpaired students.

Multidimensional Evaluation of Virtual Reality Paradigms in Clinical Neuropsychology: Application of the VR-Check Framework

Virtual reality (VR) represents a key technology of the 21st century, attracting substantial interest from a wide range of scientific disciplines. With regard to clinical neuropsychology, a multitude of new VR applications are being developed to overcome the limitations of classical paradigms. Consequently, researchers increasingly face the challenge of systematically evaluating the characteristics and quality of VR applications to design the optimal paradigm for their specific research question and study population. However, the multifaceted character of contemporary VR is not adequately captured by the traditional quality criteria (ie, objectivity, reliability, validity), highlighting the need for an extended paradigm evaluation framework. To address this gap, we propose a multidimensional evaluation framework for VR applications in clinical neuropsychology, summarized as an easy-to-use checklist (VR-Check). This framework rests on 10 main evaluation dimensions encompassing cognitive domain specificity, ecological relevance, technical feasibility, user feasibility, user motivation, task adaptability, performance quantification, immersive capacities, training feasibility, and predictable pitfalls. We show how VR-Check enables systematic and comparative paradigm optimization by illustrating its application in an exemplary research project on the assessment of spatial cognition and executive functions with immersive VR. This application furthermore demonstrates how the framework allows researchers to identify across-domain trade-offs, makes deliberate design decisions explicit, and optimizes the allocation of study resources. Complementing recent approaches to standardize clinical VR studies, the VR-Check framework enables systematic and project-specific paradigm optimization for behavioral and cognitive research in neuropsychology.

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

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

The Co-design of Hand Rehabilitation Exercises for Multiple Sclerosis Using Hand Tracking System

Multiple sclerosis (MS) often affects motor function, leading to an adverse effect on daily living. Rehabilitation is important in terms of improving mobility and activities of daily living. Virtual environments (VE) are increasing in popularity within this research area, but research in terms of VE is still rare, for both the upper and lower limb, in people with MS. Leap Motion (LM), a hand motion tracking system, has demonstrated success in stroke research but has yet to be investigated within MS. Following a co-design approach, five participants with MS discussed in a focus group (FG) their hand mobility issues, their thoughts about this technology-based rehabilitation and motivational factors. Findings were incorporated into the design of a series of gamified upper limb rehabilitation exercises, using LM, on Unity Game Engine. Three participants returned and engaged in user testing session and a FG in order to evaluate and discuss their experience. Overall participants found the proposed technology-based exercises to be engaging, immersive and a desirable approach to rehabilitation. Participant feedback underlined the usefulness of co-creation, especially in accommodating the range of motivators and user preferences. However, the study highlighted the loss of tracking of hand movements with LM as one of the limitations. Participants stated they would be likely to use this approach at home if there was a definite rehabilitation benefit and related more to visualising which muscle groups or actions they were aiming to improve.

Ability of people with post-stroke hemiplegia to self-administer FES-assisted hand therapy video games at home: An exploratory case series

Introduction

This article describes the development and initial clinical testing of an innovative home-based treatment for upper extremity hemiplegia that integrates contralaterally controlled functional electrical stimulation with hand therapy video games.

Methods

We explored the ability of seven participants with moderate-to-severe hand impairment to self-administer 12 weeks of contralaterally controlled functional electrical stimulation video game therapy at home for 10 h/week and in-lab with a therapist for four h/week. Clinical suitability was assessed by device usage logs, qualitative surveys, and clinical motor and cognitive outcomes.

Results

Three participants completed the study with > 95% compliance and four did not. Factors linked to incompletion included development of trigger finger in the non-paretic hand, acceptance of a new full-time job, residence relocation, and persistence of drowsiness from anti-spasticity medication. Those who completed the treatment perceived qualitative benefits and experienced gains in motor and cognitive outcomes.

Conclusion

Individuals with moderate-to-severe chronic post-stroke upper extremity hemiplegia can self-administer contralaterally controlled functional electrical stimulation video game therapy for up to 90 min/day at home. We also identified social and physiological factors that may preclude its use for daily home treatment. Further studies are warranted and are in progress to estimate treatment effect and optimal dose of this intervention.

Tracking the evolution of virtual reality applications to rehabilitation as a field of study

Background

Application of virtual reality (VR) to rehabilitation is relatively recent with clinical implementation very rapidly following technological advancement and scientific discovery. Implementation is often so rapid that demonstrating intervention efficacy and establishing research priorities is more reactive than proactive. This study used analytical tools from information science to examine whether application of VR to rehabilitation has evolved as a distinct field of research or is primarily a methodology in core disciplines such as biomedical engineering, medicine and psychology.

Methods

The analysis was performed in three-stages: 1) a bibliographic search in the ISI Web of Science database created an initial corpus of publications, 2) the corpus was refined through topic modeling, and 3) themes dominating the corpus from the refined search results were identified by topic modeling and network analytics. This was applied separately to each of three time periods: 1996 to 2005 (418 publications), 2006 to 2014 (1454 publications), and 2015 to mid-2018 (1269 publications).

Results

Publication rates have continuously increased across time periods with principal topics shifting from an emphasis on computer science and psychology to rehabilitation and public health. No terminology specific to the field of VR-based rehabilitation emerged; rather a range of central concepts including “virtual reality”, “virtual gaming”, “virtual environments”, “simulated environments” continue to be used. Communities engaged in research or clinical application of VR form assemblages distinguished by a focus on physical or psychological rehabilitation; these appear to be weakly linked through tele-rehabilitation.

Conclusions

Varying terms exemplify the main corpus of VR-based rehabilitation and terms are not consistent across the many scientific domains. Numerous distinguishable areas of research and clinical foci (e.g., Tele-rehabilitation, Gait & Balance, Cognitive Rehabilitation, Gaming) define the agenda. We conclude that VR-based rehabilitation consists of a network of scientific communities with a shared interest in the methodology rather than a directed and focused research field. An interlinked team approach is important to maintain scientific rigor and technological validity within this diverse group. Future studies should examine how these interdisciplinary communities individually define themselves with the goals of gathering knowledge and working collectively toward disseminating information essential to associated research communities.

End-user involvement in rehabilitation virtual reality implementation research

Purpose

Despite increasing evidence for the effectiveness of off-the-shelf and rehabilitation-specific active video games (AVGs) and virtual reality (VR) systems for rehabilitation, clinical uptake remains poor. A better match between VR/AVG system capabilities and client/therapist needs, through improved end-user involvement (UI) in VR/AVG implementation research, may increase uptake of this technology. The purpose of this paper is to review four case examples from the authors' collective experience of including end users in VR/AVG research to identify common benefits, challenges and lessons learned.

Design/methodology/approach

The authors apply knowledge and lessons learned from the four cases to make recommendations for subsequent user-engaged research design and methods, including evaluation of the impact of end UI.

Findings

A better match between VR/AVG system capabilities and client/therapist needs leads to improved end UI in all stages of VR/AVG implementation research. There are common benefits of increasing buy-in and soliciting early on the knowledge and skills of therapists as well as input from the ultimate end users: people participating in rehabilitation. Most settings have the challenges of balancing the technology requirements with the needs and goals of the practice setting and of the end users.

Research limitations/implications

Increasing end UI in VR/AVG implementation research may address issues related to poor clinical uptake. In the VR/AVG context, end users can be therapists, clients or technology developers/engineers. This paper presented four case scenarios describing the implementation of different VR/AVG systems and involving a variety of populations, end users and settings.

Originality/value

The set of recommendations for subsequent user-engaged research design and methods span the process of development, research and implementation. The authors hope that these recommendations will foster collaborations across disciplines, encourage researchers and therapists to adopt VR/AVGs more readily, and lead to efficacious and effective treatment approaches for rehabilitation clients.

Effects of virtual reality therapy on upper limb function after stroke and the role of neuroimaging as a predictor of a better response

OBJECTIVE

Virtual reality therapy (VRT) is an interactive intervention that induces neuroplasticity. The aim was to evaluate the effects of VRT associated with conventional rehabilitation for an upper limb after stroke, and the neuroimaging predictors of a better response to VRT.

METHODS

Patients with stroke were selected, and clinical neurological, upper limb function, and quality of life were evaluated. Statistical analysis was performed using a linear model comparing pre- and post-VRT. Lesions were segmented in the post-stroke computed tomography. A voxel-based lesion-symptom mapping approach was used to investigate the relationship between the lesion and upper limb function.

RESULTS

Eighteen patients were studied (55.5 ± 13.9 years of age). Quality of life, functional independence, and dexterity of the upper limb showed improvement after VRT (p < 0.001). Neuroimaging analysis showed negative correlations between the internal capsule lesion and functional recovery.

CONCLUSION

VRT showed benefits for patients with stroke, but when there was an internal capsule lesion, a worse response was observed.

Using Virtual Interactive Training Agents (ViTA) with Adults with Autism and Other Developmental Disabilities

Conversational virtual human (VH) agents are increasingly used to support role-play experiential learning. This project examined whether a Virtual Interactive Training Agent (ViTA) system would improve job interviewing skills in individuals with autism and developmental disabilities (N = 32). A linear mixed model was employed to evaluate adjusted least square mean differences of means scores on the Marino Interview Assessment Scale (MIAS) across different time points. The mean score of MIAS over all questions increased between the first ViTA session and the final face-to-face interview. Participants developed the ability to identify strengths, self-promote, self-advocate, answer situational questions, and respond to behavioral/social questions as measured by multiple evaluations using the MIAS.

Capturing Expert Knowledge for the Personalization of Cognitive Rehabilitation: Study Combining Computational Modeling and a Participatory Design Strategy

Background

Cognitive impairments after stroke are not always given sufficient attention despite the critical limitations they impose on activities of daily living (ADLs). Although there is substantial evidence on cognitive rehabilitation benefits, its implementation is limited because of time and human resource’s demands. Moreover, many cognitive rehabilitation interventions lack a robust theoretical framework in the selection of paper-and-pencil tasks by the clinicians. In this endeavor, it would be useful to have a tool that could generate standardized paper-and-pencil tasks, parameterized according to patients' needs.

Objective

In this study, we aimed to present a framework for the creation of personalized cognitive rehabilitation tasks based on a participatory design strategy.

Methods

We selected 11 paper-and-pencil tasks from standard clinical practice and parameterized them with multiple configurations. A total of 67 tasks were assessed according to their cognitive demands (attention, memory, language, and executive functions) and overall difficulty by 20 rehabilitation professionals.

Results

After assessing the internal consistency of the data—that is, alpha values from .918 to .997—we identified the parameters that significantly affected cognitive functions and proposed specific models for each task. Through computational modeling, we operationalized the tasks into their intrinsic parameters and developed a Web tool that generates personalized paper-and-pencil tasks—the Task Generator (TG).

Conclusions

Our framework proposes an objective and quantitative personalization strategy tailored to each patient in multiple cognitive domains (attention, memory, language, and executive functions) derived from expert knowledge and materialized in the TG app, a cognitive rehabilitation Web tool.

An Interactive Home-Based Cognitive-Motor Step Training Program to Reduce Fall Risk in Older Adults: Qualitative Descriptive Study of Older Adults' Experiences and Requirements

Background

Falls are a major contributor to the burden of disease in older adults. Home-based exercise programs are effective in reducing the rate and risk of falls in older adults. However, adherence to home-based exercise programs is low, limiting the efficacy of interventions. The implementation of technology-based exercise programs for older adults to use at home may increase exercise adherence and, thus, the effectiveness of fall prevention interventions. More information about older adults’ experiences when using technologies at home is needed to enable the design of programs that are tailored to older adults’ needs.

Objective

This study aimed to (1) explore older adults’ experiences using SureStep, an interactive cognitive-motor step training program to reduce fall risk unsupervised at home; (2) explore program features that older adults found encouraged program uptake and adherence; (3) identify usability issues encountered by older adults when using the program; and (4) provide guidance for the design of a future technology-based exercise program tailored to older adults to use at home as a fall prevention strategy.

Methods

This study was part of a larger randomized controlled trial. The qualitative portion of the study and the focus of this paper used a qualitative descriptive design. Data collectors conducted structured, open-ended in-person interviews with study participants who were randomly allocated to use SureStep at home for 4 months. All interviews were audiotaped and ranged from 45 to 60 min. Thematic analysis was used to analyze collected data. This study was guided by Pender’s Health Promotion Model.

Results

Overall, 24 older adults aged 70 to 97 years were interviewed. Findings suggest older adults are open to use technology-based exercise programs at home, and in the context of optimizing adherence to home-based exercise programs for the prevention of falls, findings suggest that program developers should develop exercise programs in ways that provide older adults with a fun and enjoyable experience (thus increasing intrinsic motivation to exercise), focus on improving outcomes that are significant to older adults (thus increasing self-determined extrinsic motivation), offer challenging yet attainable exercises (thus increasing perceived self-competence), provide positive feedback on performance (thus increasing self-efficacy), and are easy to use (thus reducing perceived barriers to technology use).

Conclusions

This study provides important considerations when designing technology-based programs so they are tailored to the needs of older adults, increasing both usability and acceptability of programs and potentially enhancing exercise participation and long-term adherence to fall prevention interventions. Program uptake and adherence seem to be influenced by (1) older adults’ perceived benefits of undertaking the program, (2) whether the program is stimulating, and (3) the perceived barriers to exercise and technology use. Older adults shared important recommendations for future development of technologies for older adults to use at home.

Lee Silverman Voice Treatment BIG® for a Person With Stroke

The extant literature suggests the Lee Silverman Voice Treatment BIG^® (LSVT BIG) program is an effective intervention for persons with Parkinson's disease; however, no literature or research on the use of this program as an intervention for persons with stroke exists. We examined the effects of the LSVT BIG program for a 52-yr-old community-dwelling woman with mild to moderate upper extremity hemiparesis 2 yr after a stroke and the feasibility of delivering the home exercise component of the program in a game-based format. We made measurements at pretest, posttest, and 6-wk follow-up. The participant demonstrated self-reported improvements in occupational performance and satisfaction and large improvements in upper extremity motor function. The next step in this research is to deliver LSVT BIG and a home game-based program with a larger, more diverse population of persons with chronic stroke to further determine the effectiveness and appropriateness of this intervention.

Validation of a Kinect V2 based rehabilitation game

Interactive technologies are beneficial to stroke recovery as rehabilitation interventions; however, they lack evidence for use as assessment tools. Mystic Isle is a multi-planar full-body rehabilitation game developed using the Microsoft Kinect^® V2. It aims to help stroke patients improve their motor function and daily activity performance and to assess the motions of the players. It is important that the assessment results generated from Mystic Isle are accurate. The Kinect V2 has been validated for tracking lower limbs and calculating gait-specific parameters. However, few studies have validated the accuracy of the Kinect^® V2 skeleton model in upper-body movements. In this paper, we evaluated the spatial accuracy and measurement validity of a Kinect-based game Mystic Isle in comparison to a gold-standard optical motion capture system, the Vicon system. Thirty participants completed six trials in sitting and standing. Game data from the Kinect sensor and the Vicon system were recorded simultaneously, then filtered and sample rate synchronized. The spatial accuracy was evaluated using Pearson’s r correlation coefficient, signal to noise ratio (SNR) and 3D distance difference. Each arm-joint signal had an average correlation coefficient above 0.9 and a SNR above 5. The hip joints data had less stability and a large variation in SNR. Also, the mean 3D distance difference of joints were less than 10 centimeters. For measurement validity, the accuracy was evaluated using mean and standard error of the difference, percentage error, Pearson’s r correlation coefficient and intra-class correlation (ICC). Average errors of maximum hand extent of reach were less than 5% and the average errors of mean and maximum velocities were about 10% and less than 5%, respectively. We have demonstrated that Mystic Isle provides accurate measurement and assessment of movement relative to the Vicon system.

Safety and Feasibility of a First-Person View, Full-Body Interaction Game for Telerehabilitation Post-Stroke

This study explored the feasibility and safety of pairing the Microsoft Kinect® sensor with the Oculus Rift® Head Mounted Display (HMD) as a telerehabilitation technology platform for persons post-stroke. To test initial safety, fourteen participants without disabilities (age 30 ± 8.8 years) engaged in a game-based task using the Microsoft Kinect® with a first-person view using the Oculus Rift®. These tasks were repeated for five participants post-stroke (age 56 ± 3.0 years). No significant adverse events occurred in either study population. When using the Oculus Rift® HMD, three participants without disabilities reported dizziness and nausea. All of the participants post-stroke required hands-on assistance for balance and fall prevention. The intensive nature of physical support necessary for this type of interaction limits the application as a telerehabilitation intervention. Given the increasing availability of HMDs for commercial use, it is crucial that the safety of immersive games and technologies for telerehabilitation is fully explored.

Adaptive, Multisensorial, Physiological and Social: The Next Generation of Telerehabilitation Systems

Some people require special treatments for rehabilitating physical, cognitive or even social capabilities after an accident or degenerative illness. However, the ever-increasing costs of looking after an aging population, many of whom suffer chronic diseases, is straining the finances of healthcare systems around Europe. This situation has given rise to a great deal of attention being paid to the development of telerehabilitation (TR) systems, which have been designed to take rehabilitation beyond hospitals and care centers. In this article, we propose which features should be addressed in the development of TR systems, that is, they should consider adaptive, multisensorial, physiological and social aspects. For this aim, the research project Vi-SMARt is being conducted for evaluating whether and how different technologies, such as virtual reality (VR), multi-sensorial feedback, or telemonitoring, may be exploited for the development of the next generation of TR systems. Beyond traditional aural and visual feedback, the exploitation of haptic sense by using devices such as haptic gloves or wristbands, can provide patients with additional guidance in the rehabilitation process. For telemonitoring, Electroencephalography (EEG) devices show signs of being a promising approach, not only to monitor patients’ emotions, but also to obtain neuro-feedback useful for controlling his/her interaction with the system and thus to provide a better rehabilitation experience.

Clinical Virtual Reality: Emerging Opportunities for Psychiatry

Virtual reality (VR) technology offers new opportunities for the development of innovative clinical research, assessment, and intervention tools. VR-based testing, training, teaching, and treatment approaches that would be difficult, if not impossible, to deliver with traditional methods are now being developed that take advantage of the assets that are available with VR technology. As research evidence continues to indicate clinical efficacy, VR applications are being increasingly regarded as providing innovative options for targeting the cognitive, psychological, motor, and functional impairments that result from various clinical health conditions. VR allows for the precise presentation and control of stimuli in dynamic, multisensory, 3D computer-generated simulations as well as providing advanced methods for capturing and quantifying behavioral responses. These characteristics support the rationale for the use of VR applications in clinical assessment, intervention, and training. This article begins with a brief review of the history of and rationale for the use of VR with clinical populations. It then details one use case for the clinical application of VR-the exposure-therapy treatment of anxiety disorders and posttraumatic stress disorder. Although significant work is cited in other areas of clinical VR (e.g., pain management, cognitive and physical assessment and rehabilitation, eating disorders, social skills, and clinical training), a full overview of such a broad literature is beyond the scope of this article. Thus, the authors have opted to provide more in-depth analysis of one specific clinical area that clearly illustrates how VR has been successfully applied and is supported by an encouraging and evolving scientific literature.