Virtual Rehabilitation Environment Research Articles

Effectiveness of reinforced feedback in virtual environment for upper limb rehabilitation in acute stroke

Background. Motor impairments following stroke result in loss of upper extremity function which is often persistent and disabling. Reinforced feedback in the virtual environment (RFVE) could activate mirror neuron systems which are stimulated during action observation and action execution. This study aims to evaluate the activation of proximal muscles in paretic upper limb following RFVE training. Methodology. Twenty-four stroke patients were included in the study, 12 in control group received impairment specific training and 12 in experimental group received RFVE training using Oculus quest 2 in addition to impairment specific exercise training. Surface electromyography (SEMG) of shoulder muscles of affected upper limb were recorded in both groups. Arm motor recovery was recorded using Chedoke - McMaster stroke assessment scale (CMSA). Results. Paired t-test was used to analyze the results within the group which showed improvement in the both groups and unpaired t-test was used to test the outcomes between the groups where RFVE group showed significant improvement in average muscle activity in anterior deltoid, middle deltoid and CMSA scores than control group (p < 0.005*). Conclusion. The results of this study demonstrated the beneficial effects of RFVE in upper limb training which showed improvements in muscle activation in SEMG and arm recovery in CMSA scores. RFVE training is a safe and well-accepted effective intervention in acute stroke rehabilitation that could become a successful intervention for early functional recovery.

Interactions with virtual therapists during motor rehabilitation in immersive virtual environments: a systematic review

Introduction: Virtual Reality applications for rehabilitation are increasing in popularity. In traditional as well as virtual rehabilitation, the guidance of an occupational therapist through physical and verbal interaction is often required. Several studies have attempted to implement a virtual therapist or assistant in immersive virtual environments for rehabilitation.Objective: This research aims to systematically review these studies, understanding the therapist’s role and how they are represented in the virtual environment, how the virtual therapist and patient interact and the experience of users. Our goal is to provide guidance for virtual therapist implementations into fully immersive virtual reality environments.Method: The researchers systematically reviewed the literature on virtual therapists in immersive virtual environments for motor rehabilitation (protocol prospectively registered with PROSPERO ID: CRD42022357369).Results and Conclusion: Seven studies were identified, with findings showing that virtual therapists are often human-like avatars that guide patients, requiring them to mimic the therapist’s movements. Visual, haptic, or one-direction audio feedback from the therapist to the patient was provided in five studies. The selected studies were all newly developed custom-made systems, with five systems developed using the same game engine. Studies carrying out user testing utilised several methods to understand user experience, evidencing a positive attitude from therapists and motivated and satisfied patients.Future Research: The roles of virtual therapists for motor rehabilitation needs to be explored further in rigorous empirical studies to gather data on patient and therapist user experience. Considerable potential was identified in the development of virtual therapists and therapeutic alliance in the virtual environment. Future systems should reduce manual input from therapists and include personalisation and individualised patient feedback.Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=357369], PROSPERO ID [CRD42022357369].

Correlates of Presence in a Virtual Reality Gamification Environment for Rehabilitation after Musculoskeletal Injury

Abstract Virtual reality (VR) has emerged as a powerful option for rehabilitation by providing real-time performance feedback and a safe and customized training environment. This study aimed: (1) to investigate the association between presence in the virtual environment, usability of the system, intrinsic motivation, and immersion in VR gaming designed for rehabilitation after musculoskeletal injury; and (2) to examine the users’ emotional response in terms of pleasure, arousal, and dominance after participating in VR gaming. Thirty-seven individuals aged 23.69 ± 6.98 years participated in five customized VR games designed to provide a complete rehabilitation session after a musculoskeletal injury. Pearson product-moment correlation coefficients and multiple regression analyses were used to investigate the relationship between presence in virtual environments and immersive tendencies, the usability of the system, and intrinsic motivation. The Wilcoxon Signed Rank Test was conducted to evaluate the impact of participation in VR gaming on participants’ presence in virtual environments. Significant correlations were found between presence and immersive tendencies (r = −.40, p = .017), intrinsic motivation (r = .42, p = .013), and usability of the system (r = .64, p < .001). The linear regression model explained 59% of the total variance in the presence of virtual environments. There was a statistically significant increase in the pleasure scores from the beginning to the end of the session. Our results indicate that VR may be useful in increasing adherence to treatment to recover from musculoskeletal injuries.

Rehabilitation of Lower limb balance For Post-Stroke Patients using Augmented Reality

Applications that use augmented or virtual reality can create an immersive and engaging virtual environment for motor rehabilitation using the cooperative stimulation of several sensory channels, including sight, hearing, and movement. These applications can also improve the effectiveness of rehabilitation through repetition, feedback, and encouragement. In this study, we suggest an integrated application for teaching and assessing individuals with lower limb balance disorders. The Oculus Quest VR headset-based AR-based rehabilitation programme for post-stroke patients shows potential in improving patient outcomes. It provides more fun and successful approach to rehabilitation than traditional methods. Utilizing the headset to assess temperature and blood pressure could save time and resources, but accuracy must be verified. Virtual encounters with doctors using the VR app are convenient and allow for distant progress tracking. Workout videos tailored to a patient blood pressure range can assist assure safety, but they must be suited for the patient specific needs. Overall, the programme improves access to rehabilitation services, but it requires dependable and specialized technology to achieve the best results.

Effect of Physical and Virtual Feedback on Reach-to-Grasp Movements in Virtual Environments

Object grabbing is a common interaction task in virtual environments, where the virtual and physical feedback of both the hand and the targeted object may impact its performance. To investigate these effects, we first designed a comparative study where subjects were required to reach and grasp a physical cylinder under four conditions: 1) no virtual hand and no virtual cylinder; 2) virtual cylinder without virtual hand; 3) virtual hand and cylinder; and 4) real environment. The results showed that the subjects performed with different kinematic patterns in all three virtual conditions compared to the real environment. Additionally, we found that this difference is not due to the environment or depth illusion. We performed another experiment to examine the effects of physical cylinder feedback on reach-to-grasp movement. We found that the subjects performed similarly to the physical environment only in the condition with a virtual hand and a virtual cylinder. These results suggest that feedback with virtual hand and virtual targeted object would result in similar kinematic patterns in virtual environments as in physical environments, which implies design guidelines in virtual environments for rehabilitation in patients with motor deficits.

User-Centered Virtual Environment for Poststroke Motor Rehabilitation

Abstract The use of virtual reality in the rehabilitation of lost or diminished functions after a stroke has been shown to be an innovative means in motor recovery. However, there are still several design challenges to increment the efficiency of these systems. This paper presents the development and evaluation of a nonimmersive three-dimensional virtual environment for poststroke rehabilitation of elbow flexion–extension movements, which considers the therapist as a direct user and the patient as a secondary user. The development of virtual environment was supported by the criteria of a team of specialists in physical and occupational therapy, following the philosophy of user-centered design through three iterations, and incorporating tasks based on the activities of daily living of the Barthel scale. Tests were carried out with healthy users and a patient with a diagnosis of stroke, using the system usability scale (SUS) test and a flow status questionnaire, respectively. Average satisfaction of user group without diagnosis was 79.6 out of 100 points. On the other hand, according to mean values observed with the patient, dimensions of control sense (6.33) and positive emotional experience (6.66) reflect an “optimal” experience, which indicates an enjoyment of virtual tasks despite the effort made to fulfill them.

A novel upper-limb tracking system in a virtual environment for stroke rehabilitation

BackgroundThe transfer of the behaviors of a human’s upper limbs to an avatar is widely used in the field of virtual reality rehabilitation. To perform the transfer, movement tracking technology is required. Traditionally, wearable tracking devices are used for tracking; however, these devices are expensive and cumbersome. Recently, non-wearable upper-limb tracking solutions have been proposed, which are less expensive and more comfortable. However, most products cannot track the upper limbs, including the arms and all the fingers at the same time, which limits the limb parts for tracking in a virtual environment and may lead to a limited rehabilitation effect.MethodsIn this paper, a novel virtual reality rehabilitation system (VRRS) was developed for upper-limb rehabilitation. The VRRS could track the motion of both upper limbs, integrate fine finger motion and the range of motion of the entire arm and map the motion to an avatar. To test the performance of VRRS, two experiments were designed. In the first experiment, we investigated the effect of VRRS on virtual body ownership, agency and location of the body and usability in 8 healthy participants by comparing it with a partial upper-limb tracking method based on a Leap Motion controller (LP) in the same virtual environments. In the second experiment, we examined the feasibility of VRRS in upper-limb rehabilitation with 27 stroke patients.ResultsVRRS improved the users’ senses of body ownership, agency, and location of the body. The users preferred using the VRRS to using the LP. In addition, we found that although the upper limb motor function of patients from all groups was improved, the difference between the FM scores tested on the first day and the last day of the experimental group was more significant than that of the control groups.ConclusionsA VRRS with motion tracking of the upper limbs and avatar control including the arms and all the fingers was developed. It resulted in an improved user experience of embodiment and effectively improved the effects of upper limb rehabilitation in stroke patients.Trial registrationThe study was registered at the First Affiliated Hospital of Jinan University Identifier: KY-2020–036; Date of registration: June 01, 2020.

A novel fully immersive virtual reality environment for upper extremity rehabilitation in patients with stroke.

Given the rising incidence of stroke, several technology-driven methods for rehabilitation have recently been developed. Virtual reality (VR) is a promising therapeutic technology among them. We recently developed a neuroscientifically grounded VR system to aid recovery of motor function poststroke. The developed system provides unilateral and bilateral upper extremity (UE) training in a fully immersive virtual environment that may stimulate and activate mirror neurons (MNs) in the brain necessary for UE rehabilitation. Twenty-three participants were randomized to a VR group (n=12) to receive VR intervention (8 h within 2 weeks) plus 8-h occupational therapy (OT) or a control group (n=11) to receive time-matched OT alone. Treatment effects on motor recovery and cortical reorganization were investigated using the Barthel Index (BI), Fugl-Meyer Upper Extremity (FM-UE), and resting-state fMRI. Both groups significantly improved BI (P < 0.05), reflecting the recovery of UE motor function. The VR group revealed significant improvements on FM-UE scores (P < 0.05) than the control group. Neural activity increased after the intervention, particularly in the brain areas implicating MNs, such as in the primary motor cortex. Overall, results suggested that using a neuroscientifically grounded VR system might offer additional benefits for UE rehabilitation in patients receiving OT.

Unobtrusive Inference of Affective States in Virtual Rehabilitation from Upper Limb Motions: A Feasibility Study

Virtual rehabilitation environments may afford greater patient personalization if they could harness the patient's affective state. Four states: anxiety, pain, engagement and tiredness (either physical or psychological), were hypothesized to be inferable from observable metrics of hand location and gripping strength-relevant for rehabilitation. Contributions are; (a) multiresolution classifier built from Semi-Naïve Bayesian classifiers, and (b) establishing predictive relations for the considered states from the motor proxies capitalizing on the proposed classifier with recognition levels sufficient for exploitation. 3D hand locations and gripping strength streams were recorded from 5 post-stroke patients whilst undergoing motor rehabilitation therapy administered through virtual rehabilitation along 10 sessions over 4 weeks. Features from the streams characterized the motor dynamics, while spontaneous manifestations of the states were labelled from concomitant videos by experts for supervised classification. The new classifier was compared against baseline support vector machine (SVM) and random forest (RF) with all three exhibiting comparable performances. Inference of the aforementioned states departing from chosen motor surrogates appears feasible, expediting increased personalization of virtual motor neurorehabilitation therapies.

Virtual Environments for Vestibular Rehabilitation

Virtual Environments for Vestibular Rehabilitation

Kinematic Validity of Reaching in a 2D Virtual Environment for Arm Rehabilitation After Stroke.

Increasing evidence supports the use of virtual reality for stroke rehabilitation. However, movement performance and quality may be diminished by the attributes of the virtual environment (VE), which may be detrimental to motor relearning. Our aim was to determine whether reach-to-grasp movements made in a low-cost 2DVE were kinematically similar to those made in a comparable physical environment (PE) in healthy subjects and subjects with stroke. Subjects (healthy = 15, stroke = 22) made unilateral and bilateral reach-to-grasp movements in a 2DVE and a similar PE. Arm and trunk kinematics were recorded with an optoelectronic measurement system (23 markers; 120 Hz). Temporal and spatial characteristics of the endpoint trajectory, arm and trunk movement patterns were compared between environments and groups. In each group, hand positioning at object contact time and trunk displacement were unaffected by the environment. Compared to PE, in VE, unilateral movements were less smooth and time to peak velocity was prolonged. In healthy subjects, bilateral movements were simultaneous and symmetrical in both environments. In subjects with stroke, movements were less symmetrical in VE. Aside from differences in endpoint displacement between environments, movement quality variables were unaffected by the 2DVE. Thus, using a low-cost 2DVE may be a valid approach for sensorimotor rehabilitation following stroke.

Psychiatry 2019: Exploring ocular and head kinematics in an immersive virtual environment for post-stroke neurorehabilitation - University of Amsterdam

In the Netherlands, about 43,000 people suffer a stroke each year, and more than 320,000 people have to cope with its consequences. Following a stroke, brain cells in the tissue surrounding the injury die, resulting in motor impairment and cognitive disabilities. Since current forms of rehabilitation are very tiring and repetitive for patients, novel effective rehabilitation approaches using serious gaming and virtual reality (VR) are being developed. With serious gaming, it is possible to study how people with cognitive disabilities, sometimes combined with ocular and/or motor deficits, observe their environment and process visual information. For instance, the standard tests for the assessment of post-stroke visual neglect are only useful when identifying peri-personal neglect (near space), and not personal (body) or extra-personal (far space) neglect. The shortcoming of screening for neglect in the extra-personal space can be overcome by using stereoscopic imaging in VR, which enables a three-dimensional environment. Furthermore, the field of view could be adapted during execution of different cognitive tasks to what the individual is able to see following post-stroke neglect or visual field loss. Consequently, assistive eye- and head-tracking technologies should be integrated with a VR environment to observe the gaze patterns and head movements of stroke patients. This assessment would allow more personalized rehabilitation and could possibly detect whether additional visual treatment is necessary. In this way, cognitive recovery will be accelerated by taking into account the possibilities of eye- and head-tracking in virtual environments for optimal cognitive assessment and rehabilitation following different types of stroke.

Manual wheelchair’s turning resistance: swivelling resistance parameters of front and rear wheels on different surfaces

Purpose Daily locomotion with a manual wheelchair includes curvilinear movements. However, little is known about the resisting forces in play during turning manoeuvres where the wheels are generally both rolling and swivelling. This study aimed at quantifying the swivelling resistance parameters of several wheels on different surfaces and to evaluate the effect of the curvature radius on these parameters. Materials and methods A specific test bench was designed allowing the swivelling resistance parameters of a wheel rolling while swivelling to be determined. Seven wheels (3 front and 4 rear wheels), three surfaces (plywood, linoleum and carpet), two loads (25 and 45 kg) and five curvature radii (from 0 to 0.4 m) were tested through a full factorial design experiment. Results Results showed that the wheel type was the most influential factor on swivelling resistance parameters, followed by the surface and the curvature radius. The effect of the load on swivelling resistance parameters was found negligible when compared to the influence of other factors. A predictive model for swivelling resistance parameters of the different wheel/surface combinations was proposed, as a function of the curvature radius. Conclusion This study allowed the swivelling resistance parameters of different wheel/surface combinations to be quantified, as a function of the curvature radius of the wheel trajectory. Combined with data on rolling resistance, these data could now be used to assess energy losses during real life ambulation or to achieve more realistic behaviour in virtual rehabilitation environment. Implications for rehabilitation Swivelling resistances are increased by carpet surfaces compared to tile surfaces. Conversely to rolling resistance, castors wheels are less prone to swivelling resistance than rear wheels The swivelling resistance of a wheel rolling while swivelling is decreased compared to a pure swivelling movement. Combined with data on rolling resistance, these data on swivelling resistance would allow energy loss during daily life activity to be determined or as input data for the control of wheelchair simulator in virtual environment used for rehabilitation.

Feature Evaluation of Upper Limb Exercise Rehabilitation Interactive System Based on Kinect

The virtual rehabilitation system combining virtual rehabilitation environment and upper limb rehabilitation technology is interactive and interesting, which can improve the enthusiasm and initiative of patients for rehabilitation training, improve the efficiency of rehabilitation training and improve the effect of rehabilitation treatment. This paper firstly conducts in-depth research and analysis on the research progress of the upper limb rehabilitation robot system, and deeply studies the principle and rehabilitation principle of the stroke caused by hemiplegic dyskinesia, and summarizes the goals and methods of the upper limb rehabilitation system design. Secondly, the hand motion tracking is realized by Kinect’s bone tracking, and the optimal tracking distance is determined experimentally, which verifies the stability and robustness of the tracking. Static gesture recognition adopts two gesture recognition schemes based on Kinect depth image and color space model respectively. Finally, using the rehabilitation robot and Kinect sensor as the hardware platform, the virtual rehabilitation training system experimental platform is constructed, and the horizontal rehabilitation exercise and the three-dimensional space rehabilitation exercise are respectively studied experimentally, and the exercise data obtained by using healthy subjects as the experimental object is analyzed. Based on this, the validity and feasibility of the Kinect-based upper limb exercise rehabilitation interactive system were verified.

A Multisession Evaluation of a Collaborative Virtual Environment for Arm Rehabilitation

Abstract In recent years, several multi-user virtual environments (VEs) have been developed to promote motivation and exercise intensity in motor rehabilitation. While competitive VEs have been extensively evaluated, collaborative and competitive rehabilitation VEs have seen relatively little study. Therefore, this article presents an evaluation of a VE for post-stroke arm rehabilitation that mimics everyday kitchen tasks and can be used either solo or collaboratively. Twenty subacute stroke survivors exercised with the VE for four sessions, with the first and third sessions involving solo exercise and the other two involving collaborative exercise. Exercise intensity was measured using inertial sensors while motivation was measured with questionnaires. Results showed high motivation and exercise intensity over all four sessions, and 11 of 20 participants preferred collaborative over solo exercise while only 4 preferred solo exercise. However, there were no differences in motivation, exercise duration, or exercise intensity between solo and collaborative sessions. Thus, we cannot currently claim that collaborative exercises are beneficial for upper limb rehabilitation. Future studies should evaluate other collaborative VE designs in different settings (e.g., at home) and with different participant pairs (e.g., patient-unimpaired) to find effective ways to utilize collaborative exercises in motor rehabilitation.

Cooperative Cooking: A Novel Virtual Environment for Upper Limb Rehabilitation.

Motor rehabilitation technologies commonly include virtual environments that motivate patients to exercise more often or more intensely. In this paper, we present a novel virtual rehabilitation environment in which two people work together to prepare meals. The players' roles can be fixed or undefined, and optional challenges can be added in the form of flies that must be swatted away. A preliminary evaluation with 12 pairs of unimpaired participants showed that participants prefer cooperating over exercising alone and feel less pressured when cooperating. Furthermore, participants enjoyed the addition of flies and preferred not to have defined roles. Finally, no significant decrease in exercise intensity was observed as a result of cooperation. These results indicate that cooperation could improve motor rehabilitation by increasing motivation, though the virtual environment needs to be evaluated with participants with motor impairment.

VRheab: a fully immersive motor rehabilitation system based on recurrent neural network

In this paper, a fully immersive serious game system that combines two Natural User Interfaces (NUIs) and a Head Mounted Display (HMD) to provide an interactive Virtual Environment (VE) for patient rehabilitation is proposed. Patients’ data are acquired in real-time by the NUIs, while by the HMD the VE is shown to them, thus allowing the interaction. A Long Short-Term Memory Recurrent Neural Network (LSTM-RNN), previously trained by healthy subjects (i.e., baseline), processes patients’ movements in real-time during the rehabilitation exercises to provide the degree of their performance. By comparing the functionalities of the proposed system with the ongoing state-of-the-art, it is worth noting that the reported fully immersive serious game system provides a concrete contribute to the current literature in terms of completeness and versatility. The results obtained by three rehabilitation exercises, chosen as reference case studies, performed on real patients affected by Parkinson’s disease have shown the effectiveness of the presented approach. Finally, the analysis of the feedbacks received by the therapists and patients who have used the system have highlighted remarkable results in terms of motivation, acceptance, and usability.

Motion-based equilibrium reprocessing therapy a novel treatment method for chronic peripheral vestibulopathies: A pilot study.

Rehabilitation for vestibular disease is a safe method to partially alleviate symptoms of vertigo. It was hypothesized that principles of military aviation vestibular desensitization procedures that have a success rate of more than 80% can be extrapolated to chronic vestibular disease as well.The virtual reality motion base computer-assisted rehabilitation environment was used as treatment modality in 17 patients. They were exposed to sinusoidal vertical passive whole body motion in increasing intensity for a maximum of 12 sessions. The Dizziness Handicap Inventory (DHI) was used for assessment of the subjective complaints of vertigo.The median DHI scores of 50 points at baseline dropped to 22 points (P <.001) at follow-up. Post hoc analysis showed significant differences in outcome between measurements at baseline and at the end of the treatment, between baseline and follow-up, but not between end of treatment and follow-up.This pilot study concerning motion-based equilibrium reprocessing therapy (MERT) shows that it is a simple, quick, and well-tolerated treatment option to alleviate symptoms in patients with chronic peripheral vestibulopathies.

Reaction time for processing visual stimulus in a computer-assisted rehabilitation environment

Purpose: To examine the reaction time when human subjects process information presented in the visual channel under both a direct vision and a virtual rehabilitation environment when walking was performed.Method: Visual stimulus included eight math problems displayed on the peripheral vision to seven healthy human subjects in a virtual rehabilitation training (computer-assisted rehabilitation environment (CAREN)) and a direct vision environment. Subjects were required to verbally report the results of these math calculations in a short period of time. Reaction time measured by Tobii Eye tracker and calculation accuracy were recorded and compared between the direct vision and virtual rehabilitation environment.Results: Performance outcomes measured for both groups included reaction time, reading time, answering time and the verbal answer score. A significant difference between the groups was only found for the reaction time (p = .004). Participants had more difficulty recognizing the first equation of the virtual environment.Conclusions: Participants reaction time was faster in the direct vision environment. This reaction time delay should be kept in mind when designing skill training scenarios in virtual environments. This was a pilot project to a series of studies assessing cognition ability of stroke patients who are undertaking a rehabilitation program with a virtual training environment.Implications for rehabilitationEye tracking is a reliable tool that can be employed in rehabilitation virtual environments.Reaction time changes between direct vision and virtual environment.

Effect of a mixed reality-based intervention on arm, hand, and finger function on chronic stroke.

BackgroundVirtual and mixed reality systems have been suggested to promote motor recovery after stroke. Basing on the existing evidence on motor learning, we have developed a portable and low-cost mixed reality tabletop system that transforms a conventional table in a virtual environment for upper limb rehabilitation. The system allows intensive and customized training of a wide range of arm, hand, and finger movements and enables interaction with tangible objects, while providing audiovisual feedback of the participants’ performance in gamified tasks. This study evaluates the clinical effectiveness and the acceptance of an experimental intervention with the system in chronic stroke survivors.MethodsThirty individuals with stroke were included in a reversal (A-B-A) study. Phase A consisted of 30 sessions of conventional physical therapy. Phase B consisted of 30 training sessions with the experimental system. Both interventions involved flexion and extension of the elbow, wrist, and fingers, and grasping of different objects. Sessions were 45-min long and were administered three to five days a week. The body structures (Modified Ashworth Scale), functions (Motricity Index, Fugl-Meyer Assessment Scale), activities (Manual Function Test, Wolf Motor Function Test, Box and Blocks Test, Nine Hole Peg Test), and participation (Motor Activity Log) were assessed before and after each phase. Acceptance of the system was also assessed after phase B (System Usability Scale, Intrinsic Motivation Inventory).ResultsSignificant improvement was detected after the intervention with the system in the activity, both in arm function measured by the Wolf Motor Function Test (p < 0.01) and finger dexterity measured by the Box and Blocks Test (p < 0.01) and the Nine Hole Peg Test (p < 0.01); and participation (p < 0.01), which was maintained to the end of the study. The experimental system was reported as highly usable, enjoyable, and motivating.ConclusionsOur results support the clinical effectiveness of mixed reality interventions that satisfy the motor learning principles for upper limb rehabilitation in chronic stroke survivors. This characteristic, together with the low cost of the system, its portability, and its acceptance could promote the integration of these systems in the clinical practice as an alternative to more expensive systems, such as robotic instruments.Electronic supplementary materialThe online version of this article (doi:10.1186/s12984-016-0153-6) contains supplementary material, which is available to authorized users.