A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke

Article Reviews
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THIS IS THE ARTICLE OF THE WEEK FOR JULY 1st - JULY 7th. The comment with the most likes at 4:00 PM CST on Sunday 7/7 will win $100! :cash: :cash: :cash:

Read Full Text: A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: A usability test and two clinical experiments (Free to download)
Journal: Journal of NeuroEngineering and Rehabilitation (3.582 - 2-year Impact Factor)
Year Published: 2014
Ranked 16th on our 2014-2019 list of the 50 most influential articles

Article overview for OTs

Virtual reality (VR) is a popular research topic these days. In fact, we’ve already covered an article where virtual reality was mentioned as a possible treatment for stroke, especially in the chronic stage.

But, one question I’ve had is exactly what type of virtual reality systems are being studied— and this article gives a glimpse into this quickly evolving field.

It is important to note that the virtual reality system featured in this article, the RehabMaster™, does not appear to be commercially available.

It is also important to note that MUCH has been written virtual reality and rehab since this article was published.

To get a high-level view of how this particular randomized control trial (RCT) fits with additional (and more recent) research on stroke rehab and VR, I highly recommend you check out the 2017 Cochrane Review: Virtual reality of stroke rehabilitation.
The findings of this article seem to fit with the Cochrane Review:

“We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time).”

What were the details of this study?

There was a lot going on in this article. First, it walked through the process of designing the RehabMaster™, which involved three user groups, stroke patients, occupational therapists and physiatrists.

Next, it explored the usability of the RehabMaster™ for 2x/week for 20 minutes.

After that, chronic stroke patients underwent UE rehab consisting only of RehabMaster™ training for one 30-minute session/day, five days/week for two weeks (300 minutes total).

Finally, the authors performed a prospective single-blind trial. Patients in the acute and subacute stages of stroke recovery were randomly assigned to two groups:

  1. Group 1 received conventional OT alone (10 sessions over two weeks)
  2. Group 2 received 10 minutes of conventional OT followed by 20 minutes of Rehab Master training (10 sessions over 2 weeks) (delivered by the OT.)

Assessments and results

In the first clinical experiment, with chronic stroke patients, the six patients showed slight increases in their Fugl-Meyer Assessment (FMA) scores during the intervention, but the increase was statistically insignificant.

In the second clinical experiment, the FMA score was greater in the OT + RehabMaster™ group (Group 2), but the difference was not large enough to be considered clinically significant.

Links to all assessments:
Fugl-Meyer Assessment (FMA)
Action Research Arm Test (ARAT)
Motricity Index for Motor Impairment After Stroke

Takeaways for OT

This single randomized control trial, of course, is not enough to give a full picture of the true potential of VR and stroke rehab. But it does highlight the important research questions that are currently being explored, and the article is especially helpful when read with the Cochrane Review.

Here are the questions I see this article addressing:

Should I be using VR with my stroke patients?

It is my personal opinion that VR is one tool to keep in your OT toolbox. However, VR is probably best suited for patients who had a previous interest in gaming, or patients who are looking for ways to get any edge in rehab, and are open to trying newer treatments.

What type of virtual reality should we be using?

The basic premise of this article was to explore whether a customized VR system for stroke rehab would yield strong results. The results were not statistically significant—this lines up with the Cochrane Review, which indicated commercial versus customized systems did not seem to have an impact on outcome.

This Cochrane Review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome.

What is the right amount of therapy for patients following stroke?

As I was reading about the dosage of this treatment, the 300 minutes of treatment simply did not seem like enough, as we’ve seen that the general trend is toward higher dosage. The Cochrane Review confirms this trend:

There was a trend suggesting that higher doses (more than 15 hours of total intervention) were preferable, as were customized virtual reality programs; however, these findings were not statistically significant.

Listen to a summary in podcast form


Find other platforms for listening to the OT Potential Podcast here.

What questions/thoughts does this article raise for you?

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This is a promising article and like you have mentioned, another tool in the OT toolbox. I would be interested in knowing the long-term effects of the intervention and also if it translated into independence in daily tasks. I agree that the amount of therapy time is very less. With strokes, as we all know, repetitive, long term practice yields better results and improved neuroplasticity of the brain. Virtual reality (VR) in conjunction with modified constrained induced therapy (mCIT) in natural environment may be a great combination (but appears like a tall order). In our stroke unit, we have used Wii for balance and bilateral motor coordination in conjunction with traditional OT. But no formal studies were done. I would definitely consider VR as adjunctive therapy in stroke intervention.
Thank you for another thought-provoking article.

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This is so cool Sarah - thanks for reviewing this one.

It makes me think about “virtual occupation” as a future for us. What does it mean to do things virtually, and does the brain and body respond to virtual activities just like real ones? Technology is still so limited in terms of its realism - but I can foresee a time when we can’t tell much of a difference between real and virtual. Has anyone watched Black Mirror? There are a few episodes where they have a little device you place on your temple and then you’re in a virtual world. Do you think the brain would respond to virtual movements in similar ways to real ones? And I wonder what the impact of these simulated movements would be if they felt real? I think that would be a very different kind of virtual reality - where you feel you are actually using the affected limbs rather than just operating in a virtual environment.

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Very interesting article!

I like what you said about virtual reality being another tool in our tool box. I always go back to using in the session what is meaningful for that indvidual patient. That is what is going to be motivating and encouraging. When working in the LTAC setting, I had a patient with a stroke who had a lot of trouble participating with PT, but my goodness, would she brush her hair and put her hair products in “just like normal” according to her daughter. Her daughter informed us that she was a very classy lady and had a particular way of doing things. That has always been a reminder to find what is MOST meaningful to them and start with that. With that being said, technology is the way the world is headed so I believe that virtual reality is going to be a very important aspect of therapy in the near future. I think that is great to get on the research now and be ahead when that time comes! : ) When I had younger patients who had been in accidents, virtual reality and anything technology was what they wanted to do!!

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Hey @sanchala! I agree with you, at this moment in time, if a family member of mine suffered a stroke and experienced UE motor deficits, I would want them to try modified constrained induced therapy (mCIT) in natural environment in conjunction with VR once they headed into the chronic phase. That being said, new technologies are coming on the market so quickly, I’ll be interested to see where we are at a year from now.

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I am totally using your comment to sway my husband into watching Black Mirror with me! I need to tell him it is “for work”!

I also love your comment because I was just reading about the growing popularity of motor imagery (which is showing surprising benefits just from imagining movements) and action observation therapy (which again shows surprising benefits from simply imitating another individual’s movements, which activities our powerful mirror neuron system). I think that enhanced VR could possible activate similar mechanisms!

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Found this article and episode rather interesting, especially since I do not work with this population. I also wanted to link to a few other OT podcasts (cause you know I’m a podcast junkie) that have also discussed virtual reality.

I Love OT Podcast- episode 7: OT and VR

OT Uncorked- episode 5 & 6: Virtual Reality and Computer Therapy

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@OT4LyfeSarah, you know everything about OT podcasts! OT uncorked is new to me and I am loving the premise of it! I’m excited to listen to both of these!

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I want to go back and listen to them again after reading this article. Both podcasts are amazing! Definitely worth checking out!

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I realized that I should also share this article from @lauren2! It is a few years old, but has a lot of great information in it, including rehab VR devices that you can find on the market. https://otpotential.com/blog/virtual-reality-and-occupational-therapy

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Unlike other studies about virtual reality rehabilitation this one in particular allows patients who are unable to grasp a controller to participate which is amazing! Virtual reality rehab sounds as though it would be a great tool in motivating patients, especially younger patients. Broadening this type of rehab to other diagnoses such as cerebral palsy or brachial plexus could be great for treatment sessions.

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Hi Rachel,
Thank you for sharing your personal interaction with your patient. I am an undergrad student, so I love seeing short glimpses of the occupation itself! I think that you hit it spot on when you talked about what is most meaningful to them. I think it is interesting how each generation is different as well and it is my personal opinion that the younger generations would enjoy these types of interventions! I was curious which lead me to do some research and I found a study done by Suhyun, Yumi, & Byoung-hee which was a trial that assessed the effect VR had on bilateral upper extremity function after stroke. I will put the citation below! (: Great post, thank you for sharing!

Respectfully,
Alexandria Bope, OTAS

Lee, S., Kim, Y., & Lee, B.-H. (2016). Effect of Virtual Reality-based Bilateral Upper Extremity Training on Upper Extremity Function after Stroke: A Randomized Controlled Clinical Trial. Occupational Therapy International, 23(4), 357–368. https://doi-org.elibrary.huntington.edu/10.1002/oti.1437