Heidi Sveistrup

Motor rehabilitation using virtual reality

Virtual Reality (VR) provides a unique medium suited to the achievement of several requirements for effective rehabilitation intervention. Specifically, therapy can be provided within a functional, purposeful and motivating context. Many VR applications present opportunities for individuals to participate in experiences, which are engaging and rewarding. In addition to the value of the rehabilitation experience for the user, both therapists and users benefit from the ability to readily grade and document the therapeutic intervention using various systems. In VR, advanced technologies are used to produce simulated, interactive and multi-dimensional environments. Visual interfaces including desktop monitors and head-mounted displays (HMDs), haptic interfaces, and real-time motion tracking devices are used to create environments allowing users to interact with images and virtual objects in real-time through multiple sensory modalities. Opportunities for object manipulation and body movement through virtual space provide frameworks that, in varying degrees, are perceived as comparable to similar opportunities in the real world. This paper reviews current work on motor rehabilitation using virtual environments and virtual reality and where possible, compares outcomes with those achieved in real-world applications.

Feasibility, motivation, and selective motor control: virtual reality compared to conventional home exercise in children with cerebral palsy.

Children with cerebral palsy (CP) have difficulty controlling and coordinating voluntary muscle, which results in poor selective control of muscle activity. Children with spastic CP completed ankle selective motor control exercises using a virtual reality (VR) exercise system and conventional (Conv) exercises. Ankle movements were recorded with an electrogoniometer. Children and their parents were asked to comment on their interest in the exercise programs. Greater fun and enjoyment were expressed during the VR exercises. Children completed more repetitions of the Conv exercises, but the range of motion and hold time in the stretched position were greater during VR exercises. These data suggest that using VR to elicit or guide exercise may improve exercise compliance and enhance exercise effectiveness.

Experimental Studies of Virtual Reality-Delivered Compared to Conventional Exercise Programs for Rehabilitation

This paper presents preliminary data from two clinical trials currently underway using flat screen virtual reality (VR) technology for physical rehabilitation. In the first study, we are comparing a VR-delivered exercise program to a conventional exercise program for the rehabilitation of shoulder joint range-of-motion in patients with chronic frozen shoulder. In the second study, we are comparing two exercise programs, VR and conventional, for balance retraining in subjects post-traumatic brain injury. Effective VR-based rehabilitation that is easily adapted for individuals to use both in inpatient, outpatient and home-based care could be used as a supplement or alternative to conventional therapy. If this new treatment approach is found to be effective, it could provide a way to encourage exercise and treatment compliance, provide safe and motivating therapy and could lead to the ability to provide exercises to clients in distant locations through telehealth applications of VR treatment. VR is a new technology and the possibilities for rehabilitation are only just beginning to be assessed.

Benefits of activity and virtual reality based balance exercise programmes for adults with traumatic brain injury: perceptions of participants and their caregivers.

Objective: To explore multi-dimensional benefits of exercise participation perceived by adults with traumatic brain injury (TBI) and their caregivers. Methods: Adults (n = 27, aged 18–66) with moderate or severe TBI 6 months or more earlier participated in focus groups following 6 weeks of an activity-based (ABE) or a virtual reality (VR) delivered balance exercise programme. Family members and care providers participated in separate focus groups. Perceptions related to programme participation as well as balance confidence and lower extremity function were extracted from focus group verbatim and quantitative scales, respectively. Outcomes: Benefits in three domains, psychosocial, physical and programme, were identified from transcription and analyses of focus group verbatim. Improvements were noted in balance confidence and function in both groups. Substantially greater enthusiasm and knowledge was expressed by participants in the VR group and their caregivers. Conclusions: Both exercise programmes offered benefits in addition to improved balance. The VR participants had greater improvements on quantitative measures and provided more comments expressing enjoyment and improved confidence. Applications in terms of community reintegration and quality of life are discussed.

Arm Motor Recovery Using a Virtual Reality Intervention in Chronic Stroke Randomized Control Trial

Introduction. Despite interest in virtual environments (VEs) for poststroke arm motor rehabilitation, advantages over physical environment (PE) training have not been established. Objective. The authors compared kinematic and clinical outcomes of dose-matched upper-limb training between a 3D VE and a PE in chronic stroke. Methods: Participants (n = 32) were randomized to a 3D VE or PE for training. They pointed to 6 workspace targets (72 trials, 12 trials/target, randomized) for 12 sessions over 4 weeks with similar feedback on precision, movement speed, and trunk displacement. Primary (kinematics, clinical arm motor impairment) and secondary (activity level, arm use) outcomes were compared by time (PRE, POST, and follow-up, RET), training environment, and impairment severity (mild, moderate-to-severe) using mixed-model analyses of variance (ANOVAs). Results. Endpoint speed, overall performance on a reach-to-grasp task, and activity levels increased in both groups. Only participants in the VE group improved shoulder horizontal adduction at POST (9.5°) and flexion at both POST (6.3°) and RET (13°). Impairment level affected outcomes. After VE training, the mild group increased elbow extension (RET, 25.5°). The moderate-to-severe group in VE increased arm use at POST (0.5 points) and reaching ability at RET (2.2 points). The moderate-to-severe group training in PE increased reaching ability earlier (POST, 1.7 points) and both elbow extension (10.7°) and arm use (0.4 points) at RET, but these changes were accompanied by increased compensatory trunk displacement (RET, 30.2 mm). Conclusion. VE training led to more changes in the mild group and a motor recovery pattern in the moderate-to-severe group indicative of less compensation, possibly because of a better use of feedback.

An Intensive Virtual Reality Program Improves Functional Balance and Mobility of Adolescents With Cerebral Palsy

Purpose: To examine functional balance and mobility in adolescents with cerebral palsy classified at Gross Motor Function Classification System (GMFCS) level I following an intensive short-duration virtual reality (VR) intervention. Methods: Single-subject, multiple-baseline design with 4 adolescents. Outcomes included the Community Balance and Mobility Scale (CB&M), the 6-Minute Walk Test (6MWT), the Timed Up and Down Stairs, and the Gross Motor Function Measure Dimension E. Assessments were recorded 3 to 6 times at baseline, 5 times during intervention, and 4 times at follow-up. Daily 90-minute VR intervention was completed for 5 consecutive days. Visual, statistical, and clinical significance analyses were used. Results: Statistically significant improvements were shown in all adolescents on CB&M and 6MWT. True change was recorded in all for the CB&M and in 3 for the 6MWT. Conclusions: Functional balance and mobility in adolescents with cerebral palsy classified at GMFCS level I improve with intense, short duration VR intervention, and changes are maintained at 1-month posttraining.

Video capture virtual reality: A decade of rehabilitation assessment and intervention

Abstract Background: Video capture virtual reality (VR) systems display the users on a TV or projected screen where they see themselves within a virtual environment (VE) and interact with the virtual stimuli by naturalistic movements without any encumbrance. This is one of the greatest assets of video capture VR systems, making it ideally suited as a tool for rehabilitation. Objective: To provide an overview of how single camera-based markerless video-capture technology has developed and been applied to rehabilitation over the past decade. Method: Short summaries are provided of the numerous studies that use video capture VR for motor and cognitive rehabilitation of clinical populations including stroke, spinal cord injury, traumatic brain injury, cerebral palsy and intellectual disabilities. Results and conclusions: VEs running on video capture VR systems have been shown to be feasible for clinical use for a wide variety of patient populations. The summarised papers include reports of case studies, group comparisons and review articles. Most of the studies using video-capture VR systems were aimed at improving motor aspects of individuals with neurologic conditions but some also address cognitive impairment and motivation in populations with developmental disorders. The majority of the VEs are gaming environments (involving competitive games such as virtual soccer) but functional environments (e.g. street crossing, supermarket shopping) have also been developed. The VEs have been found to be sensitive to differences in motor and cognitive ability and appear to provide an enjoyable and motivating setting for implementing a wide variety of therapeutic goals.

Determination of Sit-to-Stand Transfer Duration Using Bed and Floor Pressure Sequences

The duration of a sit-to-stand (SiSt) transfer is a representative measure of a persons status of physical mobility. This paper measured the duration unobtrusively and automatically using a pressure sensor array under a bed mattress and a floor plate beside the bed. Pressure sequences were extracted from frames of sensor data measuring bed and floor pressure over time. The start time was determined by an algorithm based on the motion of the center of pressure (COP) on the mattress toward the front edge of the bed. The end time was determined by modeling the foot pressure exerted on the floor in the wavelet domain as the step response of a third-order transfer function. As expected, young and old healthy adults generated shorter SiSt durations of around 2.31 and 2.88 s, respectively, whereas post-hip fracture and post-stroke adults produced longer SiSt durations of around 3.32 and 5.00 s. The unobtrusive nature of pressure sensing techniques used in this paper provides valuable information that can be used for the ongoing monitoring of patients within extended-care facilities or within the smart home environment.

Practice modifies the developing automatic postural response

Abstract The purpose of this study was to examine effects of experience with a postural task on components of the automatic postural response including: (1) probability of activation of functionally appropriate postural muscles; (2) number of functionally appropriate postural muscles activated; and (3) onset latencies of functionally appropriate postural muscles in infants. Infants (n=15; age 36–48 weeks old) able to pull themselves into a standing position but not able to walk independently were tested using a postural task requiring the infant to stand and balance, with support, following a forward or backward movement of the support surface (platform perturbation). Infants were tested twice at 5-day intervals. One-half of the infants, the training group, were given intense platform perturbation training on the days between test sessions. Infants in the second group were also brought into the laboratory on the days between test sessions but were not exposed to platform perturbations during those days. Electromyograms of six leg and trunk muscles were recorded during test sessions to provide muscle onset latencies, probability of muscle activation data, and the number of postural muscles activated following a perturbation. Training infants demonstrated significant increases in probability of activating functionally appropriate muscles with tibialis anterior, quadriceps, and abdominal muscles activated in response to backward sway and gastrocnemius muscle in response to forward sway. The number of functionally appropriate postural muscles activated in a single trial also increased in the training group. There were no significant changes in mean postural muscle onset latencies or number of trials with antagonist muscle coactivation for either training or control groups. These findings suggest that during development selective parameters of the automatic postural response are affected by experience with the postural task.

Virtual reality exercise improves mobility after stroke: an inpatient randomized controlled trial.

Background and Purpose— Exercise using virtual reality (VR) has improved balance in adults with traumatic brain injury and community-dwelling older adults. Rigorous randomized studies regarding its efficacy, safety, and applicability with individuals after stroke are lacking. The purpose of this study was to determine whether an adjunct VR therapy improves balance, mobility, and gait in stroke rehabilitation inpatients. Methods— A blinded randomized controlled trial studying 59 stroke survivors on an inpatient stroke rehabilitation unit was performed. The treatment group (n=30) received standard stroke rehabilitation therapy plus a program of VR exercises that challenged balance (eg, soccer goaltending, snowboarding) performed while standing. The control group (n=29) received standard stroke rehabilitation therapy plus exposure to identical VR environments but whose games did not challenge balance (performed in sitting). VR training consisted of 10 to 12 thirty-minute daily sessions for a 3-week period. Objective outcome measures of balance and mobility were assessed before, immediately after, and 1 month after training. Results— Confidence intervals and effect sizes favored the treatment group on the Timed Up and Go and the Two-Minute Walk Test, with both groups meeting minimal clinical important differences after training. More individuals in the treatment group than in the control group showed reduced impairment in the lower extremity as measured by the Chedoke McMaster Leg domain (P=0.04) immediately after training. Conclusions— This VR exercise intervention for inpatient stroke rehabilitation improved mobility-related outcomes. Future studies could include nonambulatory participants as well as the implementation strategies for the clinical use of VR. Clinical Trial Registration— URL: http://www.ANZCTR.org.au/. Unique identifier: ACTRN12613000710729.