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

Interacting with virtual characters, objects and environments: investigating immersive virtual reality in rehabilitation

PURPOSE

This pilot study aimed to (a) investigate opportunities for immersive Virtual Reality (VR) technology in communication, physical, and visual rehabilitation by examining the interaction of people without disabilities in a range of structured virtual environments; and (b) validate research protocols that might be used to evaluate the physical, visual, and verbal interaction of users in virtual worlds, and their safety while using the technology.

METHODS

Thirteen adults identifying as people without disability were exposed to VR via a head-mounted display. A video-review method was used to qualitatively code and analyse each participant's communication, movement, orientation, and support needs.

RESULTS

All participants oriented to their virtual environments sufficiently to use applications. Their spoken language was effective for interaction, although unconventional social behaviours were also observed. Two participants reported minor adverse reactions consistent with mild cybersickness.

CONCLUSION

The results provide insight into the types of environments and characters that support the greatest communicative, physical, and visual interaction in immersive VR. The tested protocols are useful to assess safety when using VR, and to observe communicative, physical, and visual interaction with virtual environments and characters. Implications for future research and use of VR with people with communication, physical and visual disability are discussed.

The Role of Immersive Virtual Reality Interventions in Pediatric Cerebral Palsy: A Systematic Review across Motor and Cognitive Domains

Background: In recent years, new technologies have been applied in cerebral palsy. Among these, immersive virtual reality is one with promising motor and cognitive effects along with the reduced costs of its application. The level of immersion of the subject in the illusional world gives the feeling of being a real part of the virtual environment. This study aims to investigate the safety and the efficacy of immersive virtual reality in children affected by cerebral palsy. Methods: PubMed, Embase, Cochrane Database of Systematic Reviews, RehabData, and Web of Science were screened up to February 2023 to identify eligible clinical studies. Results: Out of 788, we included 15 studies involving CP patients. There was high heterogeneity in the outcomes considered, and the results showed non-inferiority to conventional therapy and initial additional benefits in comparison with conventional rehabilitation. Conclusions: Immersive virtual reality emerges as a pivotal technological tool in rehabilitation, seamlessly integrating with conventional therapy within CP rehabilitation programs. Indeed, it not only enhances motivation but significantly increases children's functional capacity and abilities.

Application of immersive virtual reality mirror therapy for upper limb rehabilitation after stroke: a scoping review

Mirror therapy is a commonly used rehabilitation intervention in post stroke upper limb rehabilitation. Despite many potential technological developments, mirror therapy is routinely delivered through the use of a static mirror or mirror box. This review aims to synthesise evidence on the application of immersive virtual reality mirror therapy (IVRMT) in poststroke upper limb rehabilitation. A scoping review was performed on relevant English studies published between 2013 to 2023. Literature search was undertaken on APA PsycInfo, CINAHL, Cochrane Library, MEDLINE, PubMed and Web of Science between August 5 and 17, 2023. Additional studies were included from Google Scholar and reference lists of identified articles. A total of 224 records were identified, of which 8 full-text articles were selected for review. All included studies were published between 2019 and 2023, and from high- and upper-middle-income nations. All the studies were experimental (n = 8). The total sample size in the studies was 259, most of whom were stroke patients with upper limb weakness (n = 184). This review identified three major themes and two sub-themes based on the contents of the studies conducted on the application of IVRMT: IVRMT's technical application, feasibility and impact on clinical outcomes (motor recovery and adverse events). IVRMT was concluded to be a safe and feasible approach to post-stroke upper limb rehabilitation, offering enhanced engagement and motor recovery. However, more methodologically robust studies should be conducted to advance this area of practice, and to include a uniform IVRMT intervention protocol, dose, and use of outcome measure.

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

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

Is Virtual Reality Orientation Therapy Useful to Optimize Cognitive and Behavioral Functioning Following Severe Acquired Brain Injury? An Exploratory Study

INTRODUCTION

Severe acquired brain injury (SABI) is a leading cause of death and disability, and it is defined as a brain injury that occurs after birth due to traumatic or non-traumatic causes. Reality orientation therapy (ROT) uses repeated time-place-person orientation and meaningful stimuli to develop a better understanding of the environment and has great potential as an effective strategy to improve cognitive and behavioral functioning.

OBJECTIVE

This study aims to investigate the feasibility and potential effects of virtual reality orientation therapy (VR-rot) on optimizing cognitive and behavioral functioning and depressive symptoms post-SABI.

METHOD

Forty patients with SABI were enrolled from October 2022 to December 2023 and divided into two groups: the experimental group (EG, n = 20) received VR_rot, while the control group (CG, n = 20) received standard ROT (S_rot). All patients were evaluated with a psychometric battery, including the Mini-Mental State Examination (MMSE) and the Hamilton Rating Scale for Depression (HRS-D), administered before (T0) and after the end (T1) of rehabilitation.

RESULTS

Within-group comparisons indicated a statistically significant change in MMSE scores from T0 to T1 in the EG and CG, with the EG showing a greater improvement than the CG. Regarding HRS-D scores, the EG showed a statistically significant change. VR-ROT could be a valuable tool for improving cognitive-behavioral functioning in SABI patients.

CONCLUSIONS

The VRRS can help reduce depressive symptoms and improve the reality orientation deficit caused by traumatic brain injury and stroke on brain tissue. This study highlights the benefits of virtual reality.

Clinical effects of a novel deep learning-based rehabilitation application on cardiopulmonary function, dynamic and static balance, gait function, and activities of daily living in adolescents with hemiplegic cerebral palsy

BACKGROUND

Adolescents with hemiplegic cerebral palsy undergo conventional physical therapy (CPT) to improve static and dynamic balance, activities of daily living and cardiopulmonary function. To overcome this problem, we developed an innovative deep learning-based rehabilitation application (DRA) to provide a motivational and chaffed platform for such individuals. DRA evaluates the patients' functional abilities and diagnosis an appropriate therapeutic intervention like CPT.

METHODS

We compared the effects of DRA and CPT on 6-minute walking test (6 MWT), Borg rating of perceived exertion scale, Berg balance scale, functional ambulation category, and modified Barthel index in adolescents with hemiplegic cerebral palsy. A convenience sample of 30 adolescents with hemiplegic cerebral palsy was randomized into either the DRA or CPT group. DRA and CPT were administered to the participants, with each session lasting 30 minutes and apportioned thrice a week for a total of 4 weeks.

RESULTS

Analysis of variance was performed and the level of significance was set at P < .05. The analysis indicated that DRA showed therapeutic effects on 6 MWT, Berg balance scale, and modified Barthel index compared to CPT.

CONCLUSION

Our results provide evidence that DRA can improve cardiopulmonary function, balance, and activities of daily living more effectively than CPT in adolescents with hemiplegic cerebral palsy.

Feasibility and user-experience of a virtual environment for social connection and education after stroke: A pilot study

OBJECTIVES

To evaluate the feasibility and usability of stroke survivor participation in an 8-week virtual environment intervention that provides opportunities for social support exchanges, social network interactions, and recovery education.

MATERIALS AND METHODS

A single-group, pre- and post-test measure design was used. Descriptive statistics were used to examine enrollment and retention rates, proportion of questionnaires completed, and virtual environment process data (e.g., number of log-ins) and usability scores. Changes in pre- and post-intervention questionnaire (e.g., usability, social support, depression, anxiety, loneliness, and self-efficacy) scores were explored using Wilcoxon signed-rank tests and paired t-test.

RESULTS

Fifteen (65 %) of the eligible stroke survivors enrolled (60 % white, 27 % black), 12 (80 %) had an ischemic stroke, ages ranged from 33 to 74 years (mean 44 years), and mean months since stroke was 33 ± 23. Retention and questionnaire completion rates were both 93 % (n = 14). Survivors logged into the virtual environment a total of 122 times, logged an average of 49 min/log-in, and 12 (80 %) attended support groups and social activities. Median usability score indicated lower than average usability. Improvement trends in social support, loneliness, and depressive symptoms were found, but significant changes in mean questionnaire scores were not found.

CONCLUSIONS

Overall, the results suggest that using a virtual environment to foster social support exchanges, social network interactions, and recovery education after stroke is feasible. Similar to other chronic disease populations, stroke survivor adoption of a virtual environment likely requires ongoing technical assistance, repetition of instructions, and opportunities for practice to reinforce engagement.

TRIAL REGISTRATION

NCT05487144.

Effects of Immersive Virtual Reality on Upper-Extremity Stroke Rehabilitation: A Systematic Review with Meta-Analysis

Virtual reality (VR) is an innovative rehabilitation tool increasingly used in stroke rehabilitation. Fully immersive VR is a type of VR that closely simulates real-life scenarios, providing a high level of immersion, and has shown promising results in improving rehabilitation functions. This study aimed to assess the effect of immersive VR-based therapy for stroke patients on the upper extremities, activities of daily living (ADLs), and pain reduction and its acceptability and side effects. For this review, we gathered all suitable randomized controlled trials from PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science. Out of 1532, 10 articles were included, with 324 participants. The results show that immersive VR offers greater benefits in comparison with conventional rehabilitation, with significant improvements observed in ADLs (SMD 0.58, 95% CI 0.25 to 0.91, I2 = 0%, p = 0.0005), overall function as measured by the Fugl-Meyer Assessment (MD 6.33, 95% CI 4.15 to 8.50, I2 = 25%, p = 0.00001), and subscales for the shoulder (MD 4.96, 95% CI-1.90-8.03, I2 = 25%, p = 0.002), wrist (MD 2.41, 95% CI-0.56-4.26, I2 = 0%, p = 0.01), and hand (MD 2.60, 95% CI-0.70-4.5°, I2 = 0%, p = 0.007). These findings highlight the potential of immersive VR as a valuable therapeutic option for stroke survivors, enhancing their ADL performance and upper-limb function. The immersive nature of VR provides an engaging and immersive environment for rehabilitation.

The Upper Limb Orthosis in the Rehabilitation of Stroke Patients: The Role of 3D Printing

Stroke represents the third cause of long-term disability in the world. About 80% of stroke patients have an impairment of bio-motor functions and over half fail to regain arm functionality, resulting in motor movement control disorder with serious loss in terms of social independence. Therefore, rehabilitation plays a key role in the reduction of patient disabilities, and 3D printing (3DP) has showed interesting improvements in related fields, thanks to the possibility to produce customized, eco-sustainable and cost-effective orthoses. This study investigated the clinical use of 3DP orthosis in rehabilitation compared to the traditional ones, focusing on the correlation between 3DP technology, therapy and outcomes. We screened 138 articles from PubMed, Scopus and Web of Science, selecting the 10 articles fulfilling the inclusion criteria, which were subsequently examined for the systematic review. The results showed that 3DP provides substantial advantages in terms of upper limb orthosis designed on the patient's needs. Moreover, seven research activities used biodegradable/recyclable materials, underlining the great potential of validated 3DP solutions in a clinical rehabilitation setting. The aim of this study was to highlight how 3DP could overcome the limitations of standard medical devices in order to support clinicians, bioengineers and innovation managers during the implementation of Healthcare 4.0.

Factors associated with the effectiveness of immersive virtual therapy in alleviating depressive symptoms during sub-acute post-stroke rehabilitation: a gender comparison

BACKGROUND

The large-scale digitalization of healthcare has induced shifts in patient preferences, prompting the introduction of therapies utilizing novel technologies. In this context, the targeted application of these interventions is deemed as crucial as assessing their overall effectiveness. The aim of this study was to characterize the patient profile who benefited most from immersive virtual reality (VR) therapy.

METHODS

Based on the results from the previous randomized controlled trial study, we employed an exploratory study design to determine the factors associated with the most significant mental health improvement. A secondary analysis was conducted on a sample of 83 participants, with further analysis of participants with elevated depression symptoms, as indicated by a score of > 10 on the 30-item Geriatric Depression Scale (GDS-30). Both groups participated in a similar post-stroke rehabilitation program; however, the experimental group also received additional VR therapy through an immersive VR garden intervention. The GDS-30 was used to assess mood and depressive symptoms, and sociodemographic, cognitive status as well as stroke-related variables were considered as potential factors.

RESULTS

In both the experimental (mean change 5.3) and control groups (mean change 2.8), interventions significantly reduced depressive symptoms, with a more pronounced difference in the experimental group (p < 0.05). When examining gender differences, women exhibited greater improvement in the GDS, with mean between-group differences of 5.0 for the total sample and 6.0 for those with elevated depressive symptoms. Sociodemographic factors, cognitive status, and time from stroke were not found to be factors that alter the effectiveness of VR therapy.

CONCLUSIONS

While VR therapy as an adjunctive treatment for post-stroke rehabilitation seems especially effective for women with elevated depressive symptoms, the results should be interpreted with caution due to the study's small experimental group size. Traditional methods showed reduced effectiveness in women compared to men; thus, developing technologically advanced and gender-specific approaches can lead to more tailored therapy.

TRIAL REGISTRATION

NCT03830372 (February 5, 2019).

Rehabilitation Technologies for Chronic Conditions: Will We Sink or Swim?

INTRODUCTION

Chronic conditions such as stroke, Parkinson's disease, spinal cord injury, multiple sclerosis, vestibular disorders, chronic pain, arthritis, diabetes, chronic obstructive pulmonary disease (COPD), and heart disease are leading causes of disability among middle-aged and older adults. While evidence-based treatment can optimize clinical outcomes, few people with chronic conditions engage in the recommended levels of exercise for clinical improvement and successful management of their condition. Rehabilitation technologies that can augment therapeutic care-i.e., exoskeletons, virtual/augmented reality, and remote monitoring-offer the opportunity to bring evidence-based rehabilitation into homes. Successful integration of rehabilitation techniques at home could help recovery and access and foster long term self-management. However, widespread uptake of technology in rehabilitation is still limited, leaving many technologies developed but not adopted.

METHODS

In this narrative review, clinical need, efficacy, and obstacles and suggestions for implementation are discussed. The use of three technologies is reviewed in the management of the most prevalent chronic diseases that utilize rehabilitation services, including common neurological, musculoskeletal, metabolic, pulmonary, and cardiac conditions. The technologies are (i) exoskeletons, (ii) virtual and augmented reality, and (iii) remote monitoring.

RESULTS

Effectiveness evidence backing the use of technology in rehabilitation is growing but remains limited by high heterogeneity, lack of long-term outcomes, and lack of adoption outcomes.

CONCLUSION

While rehabilitation technologies bring opportunities to bridge the gap between clinics and homes, there are many challenges with adoption. Hybrid effectiveness and implementation trials are a possible path to successful technology development and adoption.

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.

Quantitative Comparison of Hand Kinematics Measured with a Markerless Commercial Head-Mounted Display and a Marker-Based Motion Capture System in Stroke Survivors

Upper-limb paresis is common after stroke. An important tool to assess motor recovery is to use marker-based motion capture systems to measure the kinematic characteristics of patients' movements in ecological scenarios. These systems are, however, very expensive and not readily available for many rehabilitation units. Here, we explored whether the markerless hand motion capabilities of the cost-effective Oculus Quest head-mounted display could be used to provide clinically meaningful measures. A total of 14 stroke patients executed ecologically relevant upper-limb tasks in an immersive virtual environment. During task execution, we recorded their hand movements simultaneously by means of the Oculus Quest's and a marker-based motion capture system. Our results showed that the markerless estimates of the hand position and peak velocity provided by the Oculus Quest were in very close agreement with those provided by a marker-based commercial system with their regression line having a slope close to 1 (maximum distance: mean slope = 0.94 ± 0.1; peak velocity: mean slope = 1.06 ± 0.12). Furthermore, the Oculus Quest had virtually the same sensitivity as that of a commercial system in distinguishing healthy from pathological kinematic measures. The Oculus Quest was as accurate as a commercial marker-based system in measuring clinically meaningful upper-limb kinematic parameters in stroke patients.

Merging virtual and physical experiences: extended realities in cardiovascular medicine

Technological advancement and the COVID-19 pandemic have brought virtual learning and working into our daily lives. Extended realities (XR), an umbrella term for all the immersive technologies that merge virtual and physical experiences, will undoubtedly be an indispensable part of future clinical practice. The intuitive and three-dimensional nature of XR has great potential to benefit healthcare providers and empower patients and physicians. In the past decade, the implementation of XR into cardiovascular medicine has flourished such that it is now integrated into medical training, patient education, pre-procedural planning, intra-procedural visualization, and post-procedural care. This review article discussed how XR could provide innovative care and complement traditional practice, as well as addressing its limitations and considering its future perspectives.

Virtual reality rehabilitation program on executive functions of children with specific learning disorders: a pilot study

Background

The application of Virtual Reality (VR) in the field of rehabilitation has been widely studied, because it has already proven to be an effective intervention for a variety of physical and cognitive conditions. Nevertheless, its application in pediatric rehabilitation is more recent. This pilot study aims to examine whether a VR-rehabilitation program may have positive effects on the Executive Functions (EFs) of children with Specific Learning Disorders (SLD).

Materials and methods

Twenty-four children with diagnosis of SLD participated to the study (range 7-11 years) and performed the VR-training across 6 weeks in the CARE Lab, that was designed with appropriate structural measures and ad hoc fittings, to hide the sophisticated technology necessary to allow the child to experience a rehabilitative setting with recreational and semi-immersive features. Children were evaluated across three main time-points: T0, assessment of cognitive level and EFs immediately before the start of the intervention; T1, assessment of EFs immediately after the end of VR intervention; T2, follow-up of EFs after 6 months from the end of the VR intervention. The rehabilitation programs were customized according to clinical needs and/or single patient's characteristics, proposing different games with variable complexity levels.

Results

Results showed that scores for visual attention, inhibition, flexibility, and planning abilities were significantly higher than before the intervention, and the most part of these ameliorations were maintained after 6 months.

Conclusion

These findings provide important inputs for the development of new innovative rehabilitation interventions for children with SLD that must be founded in ecological and evidence-based approaches.

Research on the Perceived Quality of Virtual Reality Headsets in Human-Computer Interaction

The progress of commercial VR headsets largely depends on the progress of sensor technology, the iteration of which often means longer research and development cycles, and also higher costs. With the continuous maturity and increasing competition of VR headsets, designers need to create a balance among user needs, technologies, and costs to achieve commercial competition advantages. To make accurate judgments, consumer feedback and opinions are particularly important. Due to the increasing maturity in the technology of commercial VR headsets in recent years, the cost has been continuously decreasing, and potential consumers have gradually increased. With the increase in consumer demand for virtual reality headsets, it is particularly important to establish a perceptual quality evaluation system. The relationship between consumer perception and product quality determined by evaluations of experience is improving. Using the research method implemented in this work, through semi-structured interviews and big data analysis of VR headset consumption, the perceptual quality elements of VR headsets are proposed, and the order of importance of perceptual quality attributes is determined by questionnaire surveys, quantitative analysis, and verification. In this study, the perceptual quality elements, including technical perceptual quality (TPQ) and value perceptual quality (VPQ), of 14 types of VR headsets were obtained, and the importance ranking of the VR headsets' perceptual quality attributes was constructed. In theory, this study enriches the research on VR headsets. In practice, this study provides better guidance and suggestions for designing and producing VR headsets so that producers can better understand which sensor technology has met the needs of consumers, and which sensor technology still has room for improvement.