Rehabilitation through virtual reality: physical activity of patients admitted to the intensive care unit

Kangaroo Stimulation Game in Tracheostomized Intensive Care-Related Dysphagia: Interventional Feasibility Study

Background

Dysphagia is common in intensive care unit (ICU) patients. Using surface electromyography (sEMG) signals as biofeedback training exercises might offer a promising path to improving swallowing function. The Rephagia biofeedback system uses sEMG to assess muscle strength, stamina, and timing of the swallowing action.

objectives

The aim of this study was to evaluate the feasibility of the Rephagia system in ICU patients with dysphagia.

Methods

This feasibility study included patients admitted to a 14-bed mixed medical-surgical ICU. All patients underwent a new tracheostomy placement during ICU stay due to persistent aspiration and ICU-acquired weakness, accompanied by verified dysphagia. Following Rephagia training, patients completed a questionnaire assessing comprehension, satisfaction, and motivation. Swallowing characteristics were assessed via mean sEMG peak values during exercise.

Results

Twenty patients with a mean age of 69.4 (SD 8.2) years were included. The means of sEMG values at the beginning of a measurement were not significantly different at baseline versus everyone's last measurement (52 µV [23 µV] vs 57 µV [22 µV]; P=.50). The means of sEMG values obtained at the end of a measurement were not significantly different at baseline versus everyone's last measurement (56 µV [18 µV] vs 59 µV [23 µV]; P=.62). However, dysphagia improved in all patients. Patients understood the importance of the game in relation to their swallowing problems (16/80, 89%), which kept them motivated to participate in the training sessions (9/18, 50%).

Conclusions

The Rephagia biofeedback system for stimulating swallowing actions in tracheotomized ICU patients with dysphagia is feasible. No relation was found between clinical improvement in swallowing function and sEMG signals.

Effects of virtual reality technology on early mobility in critically ill adult patients: a systematic review and meta-analysis

Objective

The study aimed to explore the effects of virtual reality (VR) technology on motor function rehabilitation in critically ill patients.

Methods

Adhering to the PRISMA systematic evaluation method for developing the literature ranking criteria and search strategy, the following databases were systematically searched: PubMed, Embase, Web of Science, the Cochrane Library, CNKI, Wanfang Data, Chinese Medical Journal Full-Text Database, and SINOMED. The search focused on the impact of virtual reality technology on limb function rehabilitation in critically ill patients, covering the period from the database's inception to 6 December 2024. To evaluate the quality of the included studies, the risk of bias was assessed using the RevMan 5.4 tool.

Results

A total of 11 randomized controlled trials (RCTs) published over 10 years were included, involving 880 critically ill adult patients: 435 in the experimental group and 445 in the control group. The meta-analysis showed that, compared to the control group, virtual reality technology significantly improved the Berg Balance Scale (BBS) score (MD = 3.95, 95% CI: 3.19, 4.70, p < 0.05), the Functional Independence Measure (FIM) score (MD = 0.21, 95% CI: -1.35, 1.76, p > 0.05), the Functional Ambulation Category (FAC) score (MD = 0.72, 95% CI: 0.49, 0.94, p < 0.05), the upper limb motor function (Fugl-Meyer Assessment, FMA) score (MD = 5.08, 95% CI: 3.46, 6.69, p < 0.05), and the lower limb motor function (Fugl-Meyer Assessment FMA) score (MD = 2.83, 95% CI: 1.99, 3.67, p < 0.05) of the adult critically ill patients.

Conclusion

Compared to traditional rehabilitation techniques, virtual reality technology has a better overall effect in improving motor rehabilitation in critically ill patients and enhancing balance, functional walking, and upper and lower limb motor functions. However, the effect of enhancing the functional independence of limbs is not yet evident and still needs to be confirmed by high-quality, multicenter, and large-sample clinical trials.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/ Prospero register No.: CRD42024546409.

The feasibility of virtual reality therapy for upper extremity mobilization during and after intensive care unit admission

Introduction

Early mobilization reduces long-term muscle weakness after intensive care unit (ICU) admission, but barriers (e.g., anxiety, lack of motivation) may complicate patients' adherence to exercise. Virtual reality (VR) presents immersive stimuli, which may increase motivation and adherence. This study aimed to examine the feasibility of VR-therapy using a VR-headset during ICU- and subsequent general ward admission. Furthermore, physical parameters before and after training were explored.

Materials & Methods

Ten adult ICU-patients with a median age of 71 [63-79], 70% of male registered birth sex, mechanically ventilated for ≥48 h, and willing to participate, were included. VR-therapy was offered three times a week for 20 minutes in addition to standard care. To train upper extremity functionality, patients were instructed to complete puzzles with increasing level of difficulty. Feasibility was based on patient satisfaction, session efficiency, and adherence levels during the training. Fatigue was measured after each session using the Borg Rating of Perceived Exertion Scale. Patients' hand-grip strength and Morton Mobility Index (MMI) were evaluated at the start of VR-therapy and after four weeks of training or at hospital discharge.

Results

On average, patients followed three VR-therapy sessions of 20 min per week with 13 min of actual training time, over the course of 1 to 3 weeks depending on their length of stay. Session efficiency ranged from 25% to 93%. In total, patients adhered to 60% of the VR-therapy sessions. MMI scores increased significantly from the start (26 [24-44]) to the end of the VR-therapy training period (57 [41-85], p = 0.005), indicating improved balance and mobility.

Conclusion

VR-therapy for upper extremity rehabilitation in ICU-patients is feasible during stay in the ICU and general ward.

Use of Virtual Reality Glasses During Healthcare: An Integrative Review

Integrating technology into healthcare services has direct implications for the efficacy and performance of client care. In view of this, the aim was to identify the possibilities of using virtual reality glasses in healthcare. An integrative literature review was conducted in October 2024, searching in MEDLINE, LILACS, BDENF, Scopus, Web of Science, EMBASE, and Science Direct. Original articles were included without restriction on publication period or language, whereas duplicates and those not addressing the guiding question were excluded. The level of evidence was evaluated following Melnyk and Fineout-Overholt's method. Data were synthesized in tables, figures, and in narrative form. The 47 studies in the final sample were published between 2007 and 2024, with most conducted in Turkey and predominantly clinical trials. Various models of glasses were used, with VRBox being the most cited, and video interventions were prominent. Main focuses of use included areas such as rehabilitation, invasive procedures, preoperative care, obstetrics, examinations, dentistry, and wound care. The use of virtual reality glasses has proven effective for distraction, pain reduction, and anxiety management across various health domains. Experimental studies indicate a high level of scientific evidence, which is essential for evidence-based practices; however, more objective investigations are still needed.

Feasibility and safety of interactive virtual reality upper limb rehabilitation in patients with prolonged critical illness

OBJECTIVES

This study investigated the feasibility and safety of interactive virtual reality rehabilitation (VRR) for patients with a critical illness and a long stay in the intensive care unit (ICU), as a motivational tool for rehabilitation.

DESIGN

Single-centre, non-randomised proof-of-concept clinical trial.

PARTICIPANTS

Adult, calm, and alert critically ill patients with a prolonged stay (≥8 days) in the ICU.

METHODS

Patients received interactive VRR therapy for upper limb rehabilitation with a VR-app designed specifically for use in bedridden patients in the supine position. Feasibility was assessed by time registrations, questionnaires for patients and physiotherapists, as well as recording of all perceived barriers. Safety was assessed by recording (changes in) vital clinical parameters, as well as minor and major adverse events.

RESULTS

Twenty patients participated in 79 VRR sessions. Median durations of different session components were 2 minutes (interquartile range [IQR] = 2min, 3min) for set-up and explanation to the patient, 10 minutes (IQR = 10min, 15min) for training time, and 2 minutes (IQR = 2min, 2min) for ending the session and cleaning. The median fun score given by the patients after each session was 9 (IQR = 8, 10) out of 10. Physiotherapists reported no barriers other than a few time-consuming technical problems. Reported problems by patients were all minor and mostly technical. No major and no minor adverse events occurred.

CONCLUSIONS

Interactive upper limb VRR is a feasible, safe, and appreciated tool to use in rehabilitation of critically ill patients during their prolonged ICU stay. Subsequent future studies should focus on the effects of VRR on neuromuscular and cognitive function and the socioeconomic impact of exergaming for rehabilitation purposes of ICU patients.

Theory-based and evidence-based nursing interventions for the prevention of ICU-acquired weakness in the intensive care unit: A systematic review

OBJECTIVES

To synthesise and map the evidence of a theory- and evidence-based nursing intervention for the prevention of ICU-acquired weakness and evaluate its effectiveness in terms of the incidence of ICU-acquired weakness, incidence of delirium, and length of hospital stay.

METHODS

We searched PubMed, CINAHL, MEDLINE, Academic Search Complete, Embase, Scopus, Web of Science and the Cochrane Library from database inception to November 2023. The eligible studies focused on critically ill patients in the intensive care unit, used a theory- and evidence-based nursing intervention, and reported the incidence of ICU-acquired weakness and/or used the Medical Research Council Scale. The methodological quality of the included studies was critically appraised by two authors using the appropriate Joanna Briggs Institute appraisal tool for randomised controlled trials, quasi-experimental studies, and cohort studies. Additionally, the weighted kappa coefficient was used to assess inter-rater agreement of the quality assessment. Data were reported using a narrative synthesis. This systematic review was registered by the International Prospective Register of Systematic Review (PROSPERO; CRD42023477011).

RESULTS

A total of 5162 studies were initially retrieved, and 9 studies were eventually included after screening. This systematic review revealed that preventive nursing interventions for ICU-acquired weakness mainly include (a) physiotherapy, including neuromuscular electrical stimulation and early rehabilitation, and (b) nutritional support. In addition, (c) airway management, (d) sedation and analgesia management, (e) complication prevention (delirium, stress injury and deep vein thrombosis prevention), and (f) psychological care were also provided. The theories are dominated by goal-oriented theories, and the evidence is mainly the ABCDE bundle in the included studies. The results show that theory- or evidence-based nursing interventions are effective in reducing the incidence of ICU-acquired weakness (or improving the Medical Research Council Scale scores), decreasing the incidence of delirium, shortening the length of hospital stay, and improving patients' self-care and quality of life.

CONCLUSION

Theory- and evidence-based nursing interventions have good results in preventing ICU-acquired weakness in critically ill patients. Current nursing interventions favour a combination of multiple interventions rather than just a single intervention. Therefore, preventive measures for ICU-acquired weakness should be viewed as complex interventions and should be based on theory or evidence. This systematic review is based on a small number of trials. Thus, more high-quality randomised controlled trials are needed to draw definitive conclusions about the impact of theory- and evidence-based nursing interventions on the prevention of ICU-acquired weakness.

Virtual reality as a telerehabilitation strategy for people with autism spectrum disorder during the COVID-19 quarantine scenario: physical activity, motor performance and enjoyment

PURPOSE

People with autism spectrum disorder could benefit from physical activity during the pandemic and COVID-19 restrictions, mainly to maintain adequate physical activity. We aimed to evaluate the feasibility, enjoyment, and potential effect of telerehabilitation using a serious game named 'MoveHero'.

MATERIALS AND METHODS

Registered in Clinical Trials (NCT04402034). We adopted a remotely run Telerehabilitation research design with 44 participants recruited: 22 People with ASD people and 22 non-ASD individuals.

RESULTS

All participants safely participated, 100% adherence to sessions, ∼60% enjoying the task, and significantly improved performance, with better performance for the NA group at most practice moments.

CONCLUSIONS

Our findings support both how to implement a gaming intervention and the need to investigate the efficacy of serious games to motivate moderate intensity physical activity in people with ASD.

Critical care beyond organ support: the importance of geriatric rehabilitation

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.

From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome

BACKGROUND

As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed.

MAIN BODY

This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions.

CONCLUSION

PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

Immersive Technologies in Healthcare: An In-Depth Exploration of Virtual Reality and Augmented Reality in Enhancing Patient Care, Medical Education, and Training Paradigms

BACKGROUND

Virtual reality (VR) and augmented reality (AR) are rapidly gaining traction in healthcare, offering transformative opportunities for patient care, medical education, and therapeutic interventions. Despite their potential, challenges remain regarding the implementation and integration of these technologies into existing healthcare practices.

OBJECTIVE

This review aims to explore the current applications of VR and AR in healthcare, particularly focusing on their roles in enhancing patient care and medical training, as well as identifying research gaps that hinder their widespread adoption.

METHODS

A comprehensive literature search was conducted across 2 primary databases, PubMed, and Google Scholar. The search was restricted to peer-reviewed articles, systematic reviews, meta-analyses, and randomized controlled trials (RCTs) published from 2000 to 2024. Reference lists of included articles were also examined for additional relevant studies. Inclusion criteria focused on empirical studies addressing the use of VR and/or AR in patient care or medical training, while editorial pieces, non-peer-reviewed sources, and unrelated studies were excluded. A total of 17 900 search results were identified on Google Scholar and 300 on PubMed, leading to the inclusion of 89 articles in this review.

RESULTS

The findings indicate that VR and AR technologies significantly enhance patient experiences and medical training, providing immersive and interactive environments for learning and practice. However, notable challenges include integration issues with existing electronic health record systems, the need for appropriate implementation models, and a lack of substantial evidence supporting the clinical efficacy of AR-assisted procedures.

CONCLUSION

While VR and AR hold considerable promise in revolutionizing healthcare practices, further research is essential to address existing gaps, particularly regarding implementation strategies, user acceptance, and empirical evaluation of patient outcomes and training effectiveness. Understanding the needs of healthcare professionals and patients will be critical to maximizing the impact of these technologies in clinical settings.

Effects of an interactive handgrip game on surgical patients requiring intensive care: An assessor-blinded randomized controlled trial

OBJECTIVE

To explore the effect of an interactive handgrip game on psychological distress and handgrip strength among critically ill surgical patients.

DESIGN

A randomised controlled trial.

SETTING

A surgical intensive care unit.

INTERVENTION

Participants were enrolled in the program within 48 hours of admission to the intensive care unit. Patients in the intervention group played a 20-minute interactive handgrip game twice daily for a maximum of three days in the intensive care unit in addition to routinely passive physical rehabilitation. Patients in the routine care group had a daily target of 20 min of passive physical rehabilitation as needed.

MEASUREMENT

The primary outcomes included depression, anxiety, and stress measured using the shortened version of the Depression Anxiety Stress Score scale. The secondary outcomes were perceived sleep evaluated using the Richards-Campbell Sleep Questionnaire, delirium assessed using the Intensive Care Delirium Screening Checklist, and handgrip strength measured using handgrip dynamometry within a handgrip device.

RESULTS

Two hundred and twenty-seven patients were eligible and 70 patients were recruited in the intervention (n = 35) and routine care groups (n = 35). The patients in the intervention group had lower scores (median = 6.0, 4.0, and 12.0) for depression, anxiety, and stress compared with those in the routine care group (12.0, 12.0, and 20.0; all p < 0.05). The interactive handgrip game did not significantly improve sleep quality and prevent the occurrence of delirium (both p > 0.05). The patients who received the interactive handgrip game intervention exhibited significantly enhanced handgrip strength in both hands over time (both p < 0.001).

CONCLUSION

An interactive handgrip game may benefit the psychological well-being and handgrip strength of critically ill patients.

IMPLICATIONS FOR CLINICAL PRACTICE

Interactive handgrip games is effective active exercise which should be integrated into routine nursing practice.

Virtual and augmented reality in intensive care medicine: a systematic review

BACKGROUND

Virtual reality (VR) and augmented reality (AR) are rapidly developing technologies that offer a wide range of applications and enable users to experience digitally rendered content in both physical and virtual space. Although the number of studies about the different use of VR and AR increases year by year, a systematic overview of the applications of these innovative technologies in intensive care medicine is lacking. The aim of this systematic review was to provide a detailed summary of how VR and AR are currently being used in various areas of intensive care medicine.

METHODS

We systematically searched PubMed until 1st March 2023 to identify the currently existing evidence for different applications of VR and AR for both health care providers in the intensive care unit and children or adults, who were in an intensive care unit because of a critical illness.

RESULTS

After screening the literature, a total of 59 studies were included. Of note, a substantial number of publications consists of case reports, study plans or are lacking a control group. Furthermore, study designs are seldom comparable. However, there have been a variety of use cases for VR and AR that researchers have explored. They can help intensive care unit (ICU) personnel train, plan, and perform difficult procedures such as cardiopulmonary resuscitation, vascular punctures, endotracheal intubation or percutaneous dilatational tracheostomy. Patients might benefit from VR during invasive interventions and ICU stay by alleviating stress or pain. Furthermore, it enables contact with relatives and can also assist patients in their rehabilitation programs.

CONCLUSION

Both, VR and AR, offer multiple possibilities to improve current care, both from the perspective of the healthcare professional and the patient. It can be assumed that VR and AR will develop further and their application in health care will increase.

Virtual and augmented reality in critical care medicine: the patient's, clinician's, and researcher's perspective

Virtual reality (VR) and augmented reality (AR) are aspiring, new technologies with increasing use in critical care medicine. While VR fully immerses the user into a virtual three-dimensional space, AR adds overlaid virtual elements into a real-world environment. VR and AR offer great potential to improve critical care medicine for patients, relatives and health care providers. VR may help to ameliorate anxiety, stress, fear, and pain for the patient. It may assist patients in mobilisation and rehabilitation and can improve communication between all those involved in the patient's care. AR can be an effective tool to support continuous education of intensive care medicine providers, and may complement traditional learning methods to acquire key practical competences such as central venous line placement, cardiopulmonary resuscitation, extracorporeal membrane oxygenation device management or endotracheal intubation. Currently, technical, human, and ethical challenges remain. The adaptation and integration of VR/AR modalities into useful clinical applications that can be used routinely on the ICU is challenging. Users may experience unwanted side effects (so-called "cybersickness") during VR/AR sessions, which may limit its applicability. Furthermore, critically ill patients are one of the most vulnerable patient groups and warrant special ethical considerations if new technologies are to be introduced into their daily care. To date, most studies involving AR/VR in critical care medicine provide only a low level of evidence due to their research design. Here we summarise background information, current developments, and key considerations that should be taken into account for future scientific investigations in this field.

Limited Mobility to the Bed Reduces the Chances of Discharge and Increases the Chances of Death in the ICU

BACKGROUND

Progressive mobility in the ICU has been recommended; however, the definitions of low, moderate, and high mobility in the ICU still diverge between studies. Therefore, our objective was to classify the mobility of the sample from verticalization and active withdrawal from the bed, and from that, to analyze the chances of discharge, death, and readmission to the ICU.

MATERIALS AND METHODS

This is an observational and retrospective study that consults the medical records of individuals admitted to the ICU of the University Hospital of Sergipe (HU/SE) between August 2017 and August 2018. Mobility level was classified based on the Intensive Care Unit Mobility Scale (IMS).

RESULTS

A total of 121 individuals were included. The mean age was 61.45 ± 16.45, being 53.7% female. Of these, 28 (23.1%) had low mobility, 33 (27.3%) had moderate mobility, and 60 (49.6%) had high mobility. Individuals with low mobility were 45 times more likely to die (OR = 45.3; 95% CI = 3.23-636.3) and 88 times less likely to be discharged from the ICU (OR = 0.22; 95% CI = 0.002-0.30).

CONCLUSION

Those who evolved with low mobility had a higher chance of death and a lower chance of discharge from the ICU. Moderate and high mobility were not associated with the investigated outcomes.

Clinical Effect of Virtual Reality Technology on Rehabilitation Training of Sports Injury

In order to make most patients recover most of their limb functions after rehabilitation training, virtual reality technology is an emerging human-computer interaction technology, which uses the computer and the corresponding application software to build the virtual reality environment. Completing the training tasks in the virtual environment attracts the patients to conduct repeated training in the game and task-based training mode and gradually realizes the rehabilitation training goals. For the rehabilitation population with certain exercise ability, the kinematics of human upper limbs is mainly analyzed, and the virtual reality system based on HTC VIVE is developed. The feasibility and work efficiency of the upper limb rehabilitation training system were verified by experiments. Adult volunteers who are healthy and need rehabilitation training to participate in the experiment were recruited, and experimental data were recorded. The virtual reality upper limb rehabilitation system was a questionnaire. By extracting the motion data, the system application effect is analyzed and evaluated by the simulation diagram. Follow-up results of rehabilitation training showed that the average score of healthy subjects was more than 4 points and 3.8 points per question. Therefore, it is feasible to perform upper limb rehabilitation training using the HTC VIVE virtual reality rehabilitation system.

Serious Game Platform as a Possibility for Home-Based Telerehabilitation for Individuals With Cerebral Palsy During COVID-19 Quarantine - A Cross-Sectional Pilot Study

Introduction

There is a need to maintain rehabilitation activities and motivate movement and physical activity during quarantine in individuals with Cerebral Palsy (CP).

Objective

This paper sets out to evaluate the feasibility and potential benefits of using computer serious game in a non-immersive virtual reality (VR) implemented and evaluated completely remotely in participants with CP for Home-Based Telerehabilitation during the quarantine period for COVID-19.

Methods

Using a cross-sectional design, a total of 44 individuals participated in this study between March and June 2020, 22 of which had CP (14 males and 8 females, mean age = 19 years, ranging between 11 and 28 years) and 22 typically developing individuals, matched by age and sex to the individuals with CP. Participants practiced a coincident timing game¹ and we measured movement performance and physical activity intensity using the rating of perceived exertion Borg scale.

Results

All participants were able to engage with the VR therapy remotely, reported enjoying sessions, and improved performance in some practice moments. The most important result in this cross-sectional study was the significant increasing in rating of perceived exertion (through Borg scale) in both groups during practice and with CP presenting a higher rating of perceived exertion.

Conclusion

Children with CP enjoyed participating, were able to perform at the same level as their peers on certain activities and increased both their performance and physical activity intensity when using the game, supporting the use of serious games for this group for home therapy and interactive games.

Clinical Trials Registration

https://Clinicaltrials.gov, NCT04402034. Registered on May 20, 2020.