Virtual reality for upper extremity rehabilitation in early stroke

Article Reviews
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Read Full Text: Virtual reality for upper extremity rehabilitation in early stroke: A pilot randomized controlled trial (Free to access in ProQuest via NBCOT)
Journal: Clinical Rehabilitation (2018 Impact Factor: 2.738)
Year Published: 2014
Ranked 32nd on our 2014-2019 list of the 50 most influential articles

Last week, we looked at a feasibility study of high-repetition, task-oriented UE motor rehab following stroke. And one of the big questions we got was this:

Wouldn’t this be mind-numbingly boring for the patient and the therapist?

After all, “high repetition” means we are looking at 300+ repetitions in a rehab session, so the possibility of boredom is definitely there.

One of the possible solutions to keeping rehab enjoyable and motivating is virtual reality.

And, this particular study sought to understand if, in early stroke, virtual reality (which involves high-repetition, task-specific training) improves the UE outcomes over conventional OT.

The answer, in this particular study, was that the VR therapy was not superior to conventional therapy alone.

What have we already looked at, related to virtual reality, in the club so far?

Based on our previous stroke articles, virtual reality seems to be best used as an adjunct to therapy in chronic stroke—at least for now.

This is per our look at a 2016 systematic review of UE motor rehab following stroke, and the 2017 Cochrane Review: Virtual reality of stroke rehabilitation.

It is also interesting to note that this study took place in Singapore, and the other randomized control trial of VR for stroke took place in South Korea—and both used customized VR systems. I can’t find the one used by this current study, but here is the company that made it. The system featured a local supermarket setting.

How does this article contribute to the conversation?

This article aligns with research we have already examined, which has failed to capture significant benefits to using virtual reality over conventional approaches, in the acute phase of stroke.

23 adults were randomly assigned into a control group or an intervention group.

The average time since their stroke was 16 days, so all were in the early stroke phase.

The intervention group received nine sessions consisting of 30 minutes of VR therapy over two weeks—in addition to conventional therapy (which included OT and PT).

The control group received comparable amounts of conventional therapy. (No VR therapy was delivered.)

All participants improved in all outcome measures (see below), but they all improved to a similar degree.

But, what about limitations?

Of course, reading the study does raise interesting questions.

  • Was enough therapy provided?
  • Was the sample size large enough?
  • What if both arms had been included in the VR practice? (This has shown promise in another study.)
  • Maybe the VR system itself was the problem, and it wasn’t sophisticated enough?

We can expect that the conversation about VR in therapy will continue to try to answer these questions. Technology companies obviously have a major stake in the outcomes.

Assessments

I always think it is helpful to look at the assessments used:

Takeaways for OT Practitioners

(These are my personal takeaways, and were not mentioned in the article.)

Patients keep showing improvement in these UE motor rehab studies!

It can feel like a let-down to read an article like this, where the conclusions are insignificant.

However, there was a very important tidbit in there that should not get lost:

The patients improved!

As a reminder, the 2016 systematic review we looked at probably holds true here: that functional recovery from stroke is positively influenced by goal-specific sensorimotor input through training or everyday use of the affected arm and hand.

At this time, you can be confident that your conventional therapy is just as effective as many technologies.

If you have a tendency to worry that there are fancier, more technological, interventions out there that you are not providing to your patients, you can relax a bit. At this point in time, at least in the case of acute stroke rehab, you and your clinical reasoning abilities seem to be exactly what your patients need.

Keep your eyes on this conversation.

That being said, we should continue to watch the conversation on virtual reality for stroke. There are lots of new options coming to market, and they keep getting better and better.

And, there are patients out there who are probably a great fit to use virtual reality as an adjunct to therapy. This blog post contains information about some of the rehab VR options on the market.

Listen to my takeaways in podcast form:

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

Discussion-starter questions:

What are your thoughts on balancing the use of new technology, with our most important assets: our clinical reasoning and therapeutic use of self?

Have you encountered instances in your practice where virtual was helpful to your patient or hypothetically could have been?

What would be your ideal usage of virtual reality in your therapy practice?

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I think that the age of the patient contributes to how effective the VR technology is for example, when I was doing my fieldwork we had a female patient that was in her early 30s. She was very resistant to therapy until we brought out an electronic music item. She lit up and was very invested in therapy at that point. Right before I finished they had received a new type of Saebo equipment it was like being in a video game and allowed for complete arm movement for the affected arm. Younger patients loved it!!

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Sarah, I agree with your take away regarding the patients improving in both groups. Both virtual reality software and traditional therapy are based on the principle of neuroplasticity of the brain. A therapist cannot overlook or negate the importance of this change in practice over the last two decades. Technology in and of itself has created the evidence that the brain changes at the neuron level to neurotransmitters to be manufactured and impulses to be transmitted (Mahle & Ward, 2019). Understanding neuroplasticity supports interventions which consider motor learning. Virtual reality, task-oriented, bilateral training, and mirror therapy all use this foundational concept. Motor learning offers support for mass practice, variable practice, and whole task (Birkenmeir, 2015 and Gluffrida & Maitra, 2011). Additionally, block practice appears to show immediate improvement while random practice supports long term changes (Gluffrida & Maitra, 2011). Technology and understanding how motor pathways are created in the brain add strong support for an occupational therapy practice with individuals who have experienced neurological events like a stroke. Do others have thoughts?

Dawn, I agree that age and most likely, technology skills and experiences would play a role in the effectiveness of virtual reality therapy. Children with neurological conditions are another population that I would think would benefit from virtual reality. Solomon and O’Brien (2016) include the use of the Armeo Spring Exoskeleton and Integrated Spring Mechanism and Meditouch Hand Tutor in the method used to teach hand function to an individual with cerebral palsy. Has anyone used something like this in practice?
https://www.hocoma.com/us/solutions/armeo-spring/

Birkenmeier, R. (2015). Core concept in motor recovery and rehabilitation after stroke, In T.J. Wolf & G. M. Giles (EDS.), Stroke: Interventions to support occupational performance (pp. 119—144) Bethesda MD: AOTA Press.
Gluffrida, C., &Maitra, K. (2011). Motor learning and motor control: Contemporary approaches. Philadelphia, PA: AOTA Press.
Mahle, A., & Ward, A. (2019). Adult physical conditions: Intervention Strategies for occupational therapy assistants (Vol. 1). Philadelphia, PA: F.A. Davis.
Solomon, J., & O’Brien, J. (2016). Pediatric skills for occupational therapy assistants (4th ed.). St. Louis, Missouri: Elsevier.

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Dawn you are correct and on target with your thoughts regarding age. I also think experience with using technology plays into virtual reality motivating client’s use. What do you think?

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@dawn2, it is so good to hear from someone who has experience seeing this be helpful! I think you drive home such an important point! Technology-based interventions will be more helpful/meaningful for some than others.

I like to think that this is why our role will continue to be so valuable as we enter into a rehab technology revolution—we still need a therapist’s clinical reasoning to match patients with the best interventions. There is no one-size-fits all therapy!

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@Sherry, this line just jumped off the screen to me! I’ve been reading a book about what kind of learning/training makes people more successful in their careers, and the findings are very similar. Specialization and blocked practice leads to short term gains, but over the long run (in general) varied/generalist learning has larger and more long-lasting impacts! I’ve been wondering if the same is true in motor learning, and you seem to have answered my question.

My other big takeaway that seems very relevant to OTs is that people FEEL like they are making more progress when they do repetitive practice, because they see short term gains. While varied practices feels more discouraging, even though for many types of learning it the most valuable.

I’m beginning to think that one of the most important decisions a therapists makes is whether repetitive or varied practice would be more beneficial for their patients, then educating the patient about the pros and cons of each type.

Here’s the book I’m reading: https://www.amazon.com/Range-Generalists-Triumph-Specialized-World/dp/0735214484

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Sarah, athletes are the examples where one can see the block and general practice. The block is learned to say shoot the basket from the base line but the true athlete can shoot anywhere on the court, which takes the motor memory of the shot action and the random practice of making adjustments to the variety of places the shot might happen on the court. Our patients like block practice and begin to feel they have made gains but true gains are using the movement within their daily routines. This is what makes OT unique; we immediately attempt to apply the block practice to occupations which are meaningful.
Finally, educating the client is so important so that they can see the aim of therapy and do their homework making the shift to using the new motor pattern in their occupations.
Great link and thoughts!

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This article got me thinking about the current OT interventions (especially in stroke) and our knowledge of neuroplasticity. Usually, patients perform blocked or massed practice in the form of exercises or other sensorimotor techniques (grasp/release using Bioness/Saebo) such as NDT etc. This is then followed with random practice in the form of using the UE for ADLs or other functional tasks.
I have utilized virtual reality only as an adjunct to conventional OT and more like a HEP when patients asked for it. A young acute care patient with stroke had coordination problems in her R hand. When she asked me what she could do in the evenings and I saw that she had an I-Pad, we found some coordination training apps for her to do in the evenings

Sarah, your comment on blocked versus random practice and the current book you are reading is “food for thought” (I have ordered a copy).
I searched on Pro Quest and found similar results. Some studies found promising outcomes on the LEs (speed and balance of walking) with VR but no difference in UEs. An article by Dr. Allison Belger (2013) states that “The literature on this topic is deep and consistent: blocked practice is best for beginners learning new motor patterns and basic skills. Once a certain level of mastery is involved, however, random practice seems to be the way to go.”
Maybe this is the answer we are looking for. Our patients with a stroke need that initial “blocked practice” push to gain some return and relearn function. OT practitioners need to be cognizant of this and introduce random practice to assist in transfer of learning.
References
Belger.A, (2013). Blocked Practice vs. Random Practice: Shake Things up in your Training and in your Life-Psychologywod
Carpenter, S. (2001). A blind spot in motor learning. APA Monitor : 32(6), p. 62.
Schmidt, R. A. & Wisberg, C. A. (2008). Motor Learning and Performance: A Situation-based Learning Approach . Human Kinetics Publishers.

Simon, D.A. and Bjork, A.B. (2001). Metacognition in motor learning. Journal of Experimental Psychology: Learning Memory and Cognition 27(4), 907-912.

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I have mixed last week’s and this week’s articles in my comments. I apologize if this causes confusion to some reading my post.

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I think there is real value to utilizing new technology with the right clinical reasoning skills and if it’s the appropriate patient. In my current setting (skilled nursing that is an Alzheimer’s and dementia specific facility) I don’t think virtual would be appropriate at all. Though I can see the benefits for other, maybe younger clients who use technology already or are able to learn it. I think there is still a distinct value that OT can bring when we utilize our clinical reasoning and ADL specific tasks to help client’s achieve their goals. This is very interesting to watch and see how technology can be of further use and help across all settings, but I don’t want us as OT’s to lose our distinctive value. I think there is a time, place, and current level of the patient which ties right into our own clinical reasoning as OT’s that will not go away. I love learning in this field and cannot wait to keep reading what more will come in our virtual technology.

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I think that virtual reality is really interesting! I view it as an interesting way to get repetitive movement. I know the article stated 30 minutes a day for 9 days. Is that treatment time long enough? Also, the article stated it was non-immersive therapy are there any evidence articles that state semi-immersive and immersive virtual reality treatments would be more or less beneficial?
I was looking at the Sixense company’s website to find the price of this virtual reality system (I couldn’t find it) but it got me thinking if a high tech system attains better outcomes then a simple device that basically holds your phone up to your eyes. I found a few really inexpensive cardboard devices, that allows your phone to offer the virtual reality experience. I think it could be very beneficial if it get the patient engaged and moving!

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I know! I’m amazed by the super inexpensive options that are on the market. Honestly, it seems like the research just cannot keep up. I’m linking to the Nintendo Labo below in case people haven’t seen it. It seems like the best we can do as therapists is look at the research that is out there and do our best to apply the principles to these new devices that have not been studied yet… it seems like it always comes down to clinical reasoning :slight_smile:

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Sarah the Nintendo Labo devices are creative and drive the technology industry toward create uses beyond toys and entertainment. I can think of many uses for this type of VR in kids and adults.

Grant Mitchell highlights the uses of Nintendo Wii and Sports on the web page of My OT Spot by Sarah Stronmsdorfer. Grant indicates just as noted in our discussions that Nintendo is creating cost effective technology that OT practitioners can use with clients to address motor needs. https://www.myotspot.com/incorporating-wii-occupational-therapy-treatment/

As I read Grant’s information I was thinking about a discussion I had with several of my long term care peers who think that groups are going to become important means of providing care based on the anticipated Medicare changes October 1 thus VR with evidence maybe important to consider. Berge balance scores improved with use the Nintendo’s Wii Fit activities in 22 community living older adults (Williams, Doherty, Bender, Mattox, & Tibbs, 2011). Brittany Gardner, an OT student at East Carolina University completed her thesis project and found similar results using The Four Square Step Test (FSST) and Timed Get Up and Go Test (TGUG). (Gardner & Painter, 2011)

Gardner, B., & Painter, D. J. (2011). EFFECTIVENESS OF THE NINTENDO ® WII FIT TM GAMES ON THE BALANCE OF A COMMUNITY-DWELLING OLDER ADULT IN EASTERN NORTH CAROLINA By. East Carolina University Occupational Therapy Department.

Michell, G. (2016). Incorporating the Wii into Occupational Therapy Treatment | myotspot.com. Retrieved September 26, 2019, from My OT SPOT website: https://www.myotspot.com/incorporating-wii-occupational-therapy-treatment/

Williams, B., Doherty, N. L., Bender, A., Mattox, H., & Tibbs, J. R. (2011). The Effect of Nintendo Wii on Balance: A Pilot Study Supporting the Use of the Wii in Occupational Therapy for the Well Elderly. Occupational Therapy In Health Care, 25(2–3), 131–139. https://doi.org/10.3109/07380577.2011.560627

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I agree very much with the initial post by Dawn and also feel ideally for effective use the virtual reality would be most beneficially applied to the younger patients. In addition, as the stroke population demographics are changing as we see younger and younger clients it’s nice to see this incorporated into treatment and in keeping with client centered practice and helping clients focus on activities they find meaningful or even enjoyable -the beauty and art of therapy and our practice.

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Yet another interesting article with accompanying insightful comments! I have no personal experience working with VR as a supplement to traditional therapy, but one of my professors from my OT program, Allison Ellington OTD, MS, OTR/L, is very involved in the development of that technology as well as embedding it effectively into traditional treatment. For those of you who are interested I have included links highlighting the research and development that she is involved in below:

Saebo Announces FDA Clearance of SaeboVR – World’s First Virtual ADL Rehabilitation System
Murphy Deming Plays Key Role in VR Therapy Program
Video Game Helping Patients Rehab from Stroke
Virtual Activities of Daily Living for Recovery of Upper Extremity Motor Function
Upper Extremity Function Assessment Using a Glove Orthosis and VR System

During the program we had the opportunity to demo this program and equipment and I would describe it as semi-immersive since it does not involve using a VR headset. I’d say it’s closest to using an Xbox Kinect since that’s actually the video game platform it’s constructed on. I hope that this research is helpful for those of you who may be interested in utilizing VR in the future!

Side note: Dr. Ellington was also the one who sparked my interest in joining a professional journal club after graduation, so here I am! :smiley:

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Whoa! How awesome that you had Dr. Ellingson as a professor! I am obviously SUPER BIASED, but I feel like I can tell when OT have been part of the development of new tech projects- and I’m always way more excited about those products!

I need to read the last article you linked to tomorrow, when my mind is more fresh. But, just off the top of my head it makes sense to use a VR system for assessment, but that had never occurred to me! We know that algorithms perform best when there are more strict and known parameters, and assessments are some of the most structured tasks we do as therapists!

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Maggie,
Thank you for these resources. Will definitely check them out.

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OH MY GOODNESS!!! This is my favorite topic; I have thought so much on the topic. I shall try to be brief though I can hardly contain myself. My thoughts points first followed by a brief description.

  1. VR as Context/environment, not treatment
  2. Off the shelf systems as more usable/accessible
  3. I still use this research, today and this last week even.
  4. The article by (Yin et al., 2014)

ONE: In completing my thesis project on the use of Nintendo Wii and Xbox Kinect in rehab, my perspective/paradigm was changed. Research and literature indicated VR is not really a treatment but a context, much like we don’t have Garage therapy or Kitchen therapy, but use those contexts to work with people. The therapeutic use of VR is the OT grading, modifying, adapting, and utilizing the VR as a tool or context to facilitate movement. Though certainly this statement does not negate the value of the research.

TWO: I as a student, I was enamored by the beautiful and cutting edge products often running from 10,000$ up to 70,000$ for AROM VR products. However, surveys have indicated the complexity of the device reduces therapists use of it. Plus, if a client cannot use a VR device without a therapist, then the therapist can just as well provide the assist to an off-the shelf device. The Nintendo for example, is the easiest reported system to use, clients are familiar with them and often have them in their homes, and the graphics and games are usually superior by the game developers than the graphics and games of start-up rehab tech companies, unfortunately.

THREE: At my last PRN rehab we utilized the Nintendo Wii on a push cart regularly and I educated my staff on the research and technical operation and it was motivating to the clients. Surveys have suggested older adults report satisfaction as well as youth. I bought a Nintendo Wii for 20$ unused at a garage sale and donated it to my previous psychiatric unit, and it became a daily group activity outside of my OT groups. Last weekend, I found the Nintendo Wii at my new Inpatient Rehab job hid away unused in the cabinet. I set it up on a cart with a TV, charged the controllers, and it has been used non-stop since, even brought to patients rooms so it can be used outside of therapy. HOW MOTIVATING!!!

FOUR: I used this Yin et al., 2014 article in my thesis project! Also, I submitted a similar Yin et al., 2013 article for a CAP review. My primary critique is that I think again, the VR is really a context rather than a treatment, so that if you add any productive treatment (cooking, building, cleaning, fishing etc) on top of “conventional therapy) I believe it’s the added intensity or time of therapy as a contributor to positive results (assuming skilled grading and modification of the task is completed by the therapist). However, I appreciate their study design, parameters, and randomized control trials are too few sometimes so this was a great study.

A more versed and studied OT on the topic however is Rachel Proffitt, an OT researcher who I cited in my thesis project. Her Twitter is: @games4rehabOT

Lastly, I’m curious how often other OT use Wii or Xbox, and if they find the technical operation or the clinical use more challenging?

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Very interesting to read! I love this concept and idea, and enjoyed reading comments by members. A few things I personally think need to be considered are the cost of the VR, getting clients to understand the value/benefits of it (buy-in!), therapist training (including appropriate use of VR), and reimbursement challenges/considerations

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