Judith E. Deutsch

Use of a Low-Cost, Commercially Available Gaming Console (Wii) for Rehabilitation of an Adolescent With Cerebral Palsy

Background and Purpose: The purpose of this retrospective and prospective case report is to describe the feasibility and outcomes of using a low-cost, commercially available gaming system (Wii) to augment the rehabilitation of an adolescent with cerebral palsy. Patient and Setting: The patient was an adolescent with spastic diplegic cerebral palsy classified as GMFCS level III who was treated during a summer session in a school-based setting. Intervention: The patient participated in 11 training sessions, 2 of which included other players. Sessions were between 60 and 90 minutes in duration. Training was performed using the Wii sports games software, including boxing, tennis, bowling, and golf. He trained in both standing and sitting positions. Outcomes: Three main outcome measures were used: (1) visual-perceptual processing, using a motor-free perceptual test (Test of Visual Perceptual Skills, third edition); (2) postural control, using weight distribution and sway measures; and (3) functional mobility, using gait distance. Improvements in visual-perceptual processing, postural control, and functional mobility were measured after training. Discussion and Conclusions: The feasibility of using the system in the school-based setting during the summer session was supported. For this patient whose rehabilitation was augmented with the Wii, there were positive outcomes at the impairment and functional levels. Multiple hypotheses were proposed for the findings that may be the springboard for additional research. To the authors’ knowledge, this is the first published report on using this particular low-cost, commercially available gaming technology for rehabilitation of a person with cerebral palsy.

Effects of Training With a Robot-Virtual Reality System Compared With a Robot Alone on the Gait of Individuals After Stroke

Background and Purpose— Training of the lower extremity (LE) using a robot coupled with virtual environments has shown to transfer to improved overground locomotion. The purpose of this study was to determine whether the transfer of training of LE movements to locomotion was greater using a virtual environment coupled with a robot or with the robot alone. Methods— A single, blind, randomized clinical trial was conducted. Eighteen individuals poststroke participated in a 4-week training protocol. One group trained with the robot virtual reality (VR) system and the other group trained with the robot alone. Outcome measures were temporal features of gait measured in a laboratory setting and the community. Results— Greater changes in velocity and distance walked were demonstrated for the group trained with the robotic device coupled with the VR than training with the robot alone. Similarly, significantly greater improvements in the distance walked and number of steps taken in the community were measured for the group that trained with robot coupled with the VR. These differences were maintained at 3 months’ follow-up. Conclusions— The study is the first to demonstrate that LE training of individuals with chronic hemiparesis using a robotic device coupled with VR improved walking ability in the laboratory and the community better than robot training alone.

Motor Imagery in Physical Therapist Practice

Motor imagery is the mental representation of movement without any body movement. Abundant evidence on the positive effects of motor imagery practice on motor performance and learning in athletes, people who are healthy, and people with neurological conditions (eg, stroke, spinal cord injury, Parkinson disease) has been published. The purpose of this update is to synthesize the relevant literature about motor imagery in order to facilitate its integration into physical therapist practice. This update also will discuss visual and kinesthetic motor imagery, factors that modify motor imagery practice, the design of motor imagery protocols, and potential applications of motor imagery.

Virtual Reality for Gait Training: Can It Induce Motor Learning to Enhance Complex Walking and Reduce Fall Risk in Patients With Parkinson's Disease?

BACKGROUND Gait and cognitive disturbances are common in Parkinsons disease (PD). These deficits exacerbate fall risk and difficulties with mobility, especially during complex or dual-task walking. Traditional gait training generally fails to fully address these complex gait activities. Virtual reality (VR) incorporates principles of motor learning while delivering engaging and challenging training in complex environments. We hypothesized that VR may be applied to address the multifaceted deficits associated with fall risk in PD. METHODS Twenty patients received 18 sessions (3 per week) of progressive intensive treadmill training with virtual obstacles (TT + VR). Outcome measures included gait under usual-walking and dual-task conditions and while negotiating physical obstacles. Cognitive function and functional performance were also assessed. RESULTS Patients were 67.1 ± 6.5 years and had a mean disease duration of 9.8 ± 5.6 years. Posttraining, gait speed significantly improved during usual walking, during dual task, and while negotiating overground obstacles. Dual-task gait variability decreased (ie, improved) and Trail Making Test times (parts A and B) improved. Gains in functional performance measures and retention effects, 1 month later, were also observed. CONCLUSIONS To our knowledge, this is the first time that TT + VR has been used for gait training in PD. The results indicate that TT + VR is viable in PD and may significantly improve physical performance, gait during complex challenging conditions, and even certain aspects of cognitive function. These findings have important implications for understanding motor learning in the presence of PD and for treating fall risk in PD, aging, and others who share a heightened risk of falls.

A Stewart Platform-Based System for Ankle Telerehabilitation

The “Rutgers Ankle” is a Stewart platform-type haptic interface designed for use in rehabilitation. The system supplies six-DOF resistive forces in response to virtual reality-based exercises running on a host PC. The Stewart platform uses double-acting pneumatic cylinders, linear potentiometers as position sensors, and a six-DOF force sensor. The Rutgers Ankle controller contains an embedded Pentium board, pneumatic solenoid valves, valve controllers, and associated signal conditioning electronics. Communication with the host PC is over a standard RS232 line. The platform movement and output forces are transparently recorded by the host PC in a database. This database can be accessed remotely over the Internet. Thus, the Rutgers Ankle Orthopedic Rehabilitation Interface will allow patients to exercise at home while being monitored remotely by therapists. A prototype was constructed, and proof-of-concept trials were conducted at the University of Medicine and Dentistry of New Jersey. The results indicate that the system works well as a diagnostic tool. The subjective evaluation by patients was very positive. Further medical trials are needed before the system clinical efficacy in rehabilitation can be established.

Post-Stroke Rehabilitation with the Rutgers Ankle System: A Case Study

The Rutgers Ankle is a Stewart platform-type haptic interface designed for use in rehabilitation. The system supplies six-degree-of-freedom (DOF) resistive forces on the patients foot, in response to virtual reality-based exercises. The Rutgers Ankle controller contains an embedded Pentium board, pneumatic solenoid valves, valve controllers, and associated signal conditioning electronics. The rehabilitation exercise used in our case study consists of piloting a virtual airplane through loops. The exercise difficulty can be selected based on the number and placement of loops, the airplane speed in the virtual environment, and the degree of resistance provided by the haptic interface. Exercise data is stored transparently, in real time, in an Oracle database. These data consist of ankle position, forces, and mechanical work during an exercise, and over subsequent rehabilitation sessions. The number of loops completed and the time it took to do that are also stored online. A case study is presented of a patient nine months post-stroke using this system. Results showed that, over six rehabilitation sessions, the patient improved on clinical measures of strength and endurance, which corresponded well with torque and power output increases measured by the Rutgers Ankle. There were also substantial improvements in task accuracy and coordination during the simulation and the patients walking and stair-climbing ability.

Home-Based Motor Imagery Training for Gait Rehabilitation of People With Chronic Poststroke Hemiparesis

OBJECTIVE To test the feasibility and efficacy of a home-based motor imagery gait training program to improve walking performance of individuals with chronic poststroke hemiparesis. DESIGN Nonrandomized controlled trial. SETTING Local facility. PARTICIPANTS Participants (N=17) were community-dwelling volunteers with hemiparesis caused by a unilateral stroke that occurred at least 3 months before the study. INTERVENTION Participants received 15 minutes of supervised imagery gait training in their homes 3 days a week for 6 weeks. The intervention addressed gait impairments of the affected lower limb and task-specific gait training. Walking ability was evaluated by kinematics and functional scales twice before the intervention, 3 and 6 weeks after the intervention began, and at the 3-week follow-up. MAIN OUTCOME MEASURES Spatiotemporal, kinematic, and functional walking measurements. RESULTS Walking speed increased significantly by 40% after training, and the gains were largely maintained at the 3-week follow-up. The effect size of the intervention on walking speed was moderate (.64). There were significant increases in stride length, cadence, and single-support time of the affected lower limb, whereas double-support time was decreased. Improvements were also noted on the gait scale of the Tinetti Performance-Oriented Mobility Assessment as well as in functional gait. Sixty-five percent of the participants advanced 1 walking category in the Modified Functional Walking Categories Index. CONCLUSIONS Although further study is recommended, the findings support the feasibility and justify the incorporation of home-based motor imagery exercises to improve walking skills for poststroke hemiparesis.

Effects of virtual reality training on gait biomechanics of individuals post-stroke.

OBJECTIVE To evaluate gait biomechanics after training with a virtual reality (VR) system and to elucidate underlying mechanisms that contributed to the observed functional improvement in gait speed and distance. DESIGN A single blind randomized control study. SETTING Gait analysis laboratory in a rehabilitation hospital and the community. PARTICIPANTS Fifteen men and three women with hemiparesis caused by stroke. INTERVENTIONS Subjects trained on a six-degree of freedom force-feedback robot interfaced with a VR simulation. Subjects were randomized to either a VR group (n=9) or non-VR group (NVR, n=9). Training was performed three times a week for 4 weeks for approximately 1h each visit. MAIN OUTCOME MEASURES Kinematic and kinetic gait parameters. RESULTS Subjects in the VR group demonstrated a significantly larger increase in ankle power generation at push-off as a result of training (p=0.036). The VR group had greater change in ankle ROM post-training (19.5%) as compared to the NVR group (3.3%). Significant differences were found in knee ROM on the affected side during stance and swing, with greater change in the VR group. No significant changes were observed in kinematics or kinetics of the hip post-training. CONCLUSIONS These findings are encouraging because they support the potential for recovery of force and power of the lower extremity for individuals with chronic hemiparesis. It is likely that the effects of training included improved motor control at the ankle, which enabled the cascade of changes that produced the functional improvements seen after training.

Nintendo Wii Sports and Wii Fit Game Analysis, Validation, and Application to Stroke Rehabilitation

Abstract Background: Interactive video gaming has become ubiquitous in the practice of rehabilitation. The Nintendo Wii is one such system. Interactive gaming can promote intensive task-based therapy in a manner that is motivating for the user. Widespread enthusiasm for consoles and their games prompted us to analyze the games for their rehabilitation elements related to improving balance and mobility for individuals poststroke. Purpose: The purpose of this article is to provide a game analysis for clinical application and evaluation of the game elements for research on interactive video gaming. Methods: Using a team of game players and raters, 5 tables (1 for the Wii Sports and 4 for the Wii Fit) were developed and validated. The tables consist of 3 categories: game description, impairments targeted (strength, endurance, balance, and coordination), and feedback provided (knowledge of performance [KP] and knowledge of results [KR]). Two domain content experts established face validity. Construct validity was performed by 2 therapist-raters who had more than 15 years’ clinical experience and postgraduate training in motor learning. Observations about the games including the fidelity of the interfaces, the nature of the feedback, and some of the challenges to adapting the games for rehabilitation are presented. Results: An 80% agreement between raters set as the criterion for establishing the construct validity was met for feedback evaluation. There was 100% agreement on impairment ratings. Games provide a greater amount of KR compared with KP. Conclusion: Given the preponderance of KR, therapists will need to monitor motor performance. Adaptation of interactive video consoles for rehabilitation requires careful evaluation of the games’ attributes using relevant rehabilitation construits.

Technical and Patient Performance Using a Virtual Reality-Integrated Telerehabilitation System: Preliminary Finding

Telerehabilitation is the provision of rehabilitation services at a distance by a therapist at a remote location. Integration with virtual reality (VR) is a relatively new addition to this field. This paper describes the technical and patient performance of a telerehabilitation application the remote console (ReCon) that is integrated with a VR system. The VR system consists of the Rutgers Ankle prototype robot, a local PC which is connected with a remote PC connected over the Internet. Six individuals in the chronic phase poststroke participated in a four week training program. They used the robot to interact with two VR simulations, while the therapist was in the same room during the first three weeks or in another room during the fourth week. Technical and patient performance was assessed in the transition from the third to the fourth week of training. Technical performance of the system was assessed based on bandwidth and lag of message transmission, which were found to be suitable for clinic-to-clinic communication. Patient performance (in terms of accuracy of ankle movement, exercise duration and training efficiency, mechanical power of the ankle, and number of repetitions) did not decrease during telerehabilitation in the fourth week. These preliminary findings over a short telerehabilitation intervention support the feasibility of remote monitoring of VR-based telerehabilitation without adverse effects on patient performance