New technologies have emerged as modern treatment approaches in stroke rehabilitation. Virtual reality (VR) and interactive gaming are just some of them.

New technologies new opportunities
Virtual reality (VR) based applications have begun to play an increasing role in motor rehabilitation after stroke. As VR is rapidly being adopted in the clinical setting, commercial gaming consoles bring an affordable solution for the average consumer.
Providing an interactive motivational environment, VR is facilitating motor learning through multimodal sensory information. (1, 2)

Background on VR
Before we go deeper into the world of VR, some commonly used terms should be defined.
Virtual reality or VR is often used to describe any simulation created with computer hardware. VR is typically used in gaming and simulation environments.

Overall, VR is a simulated environment with virtual objects and projected images. Various forms of feedback are provided to enhance the experience. Normally visual, auditory and sometimes other forms of feedback are given to support the illusion and enable for example motor learning. (3)

Immersive VR

Often the display or the intensity of the experience is not mentioned in VR applications, this is the reason why it’s hard to determine what kind of VR is used.

Immersive VR is the “real deal” in the VR business.
Immersive VR is a simulation of a first-person view, through a head-mounted display or a stereoscopic screen. An artificial environment replaces the user’s real-world surroundings to fully engage with the given task.

Non-immersive VR, on the other hand, is a mirror-image view on a screen where the user is represented by an avatar within the VR or is not visible at all. (4)

Immersiveness is an important element of VR application and determines the extent of the experience.
Immersiveness normally regulates the amount of engagement in VR.
There are some points of measurement that define immersiveness:

  • The amount of reality
  • Continuity of surroundings
  • Conformance to human vision
  • Freedom of movement
  • Physical interaction
  • Physical feedback
  • Narrative engagement
  • 3D audio

All these factors are important for an immersive VR experience. Adapting them into the health and therapy setting requires experts and creative minds.

VR in health

VR in the form of 3D projections and 360 degrees screens as well as immersive VR simulation provide opportunities in the health sector. With commercial gaming consoles, in particular, VR is available and has been rapidly adopted for a clinical setting.
VR tools for teaching, learning, and training are being developed around the world.
Immersive VR simulation for surgery, learning neuroanatomy and neurosurgical training are just some applications.
Studies suggest that VR can give a more positive learner experience and increase study motivation in medical students. Furthermore, VR can improve learning gain and clinical outcomes for rehabilitation. (5, 6, 7, 8, 9, 10)

VR in therapy

As mentioned before, VR is not always VR. The level of immersiveness is not usually determined in studies and can lead to miss interpretation if not considered. VR in studies is often presented as any form of interactive gaming or desktop applications.
Immersive VR used in therapy, on the other hand, can allow a patient to fully engage with the given environment and task.
As a result, VR, in this context, will always be used synonymously to immersive VR.

One key element of VR-based rehabilitation is movement visualization. Positive effects like body scheme integration and motor learning are only some promising approaches with VR in neurorehabilitation. Repetitive customized high-intensity training, multimodal feedback, and improved motivation are several positive factors that are presented by studies right now. (1)

As an engaging intervention, VR requires an individual to actively participate. Positive reinforcement encourages repetition and the inviting nature of VR can assist in the rehabilitation process. VR engages the user in long-term exercise and provides a challenging and motivating environment. (11, 12)

The transfer into real-life scenarios and to functional activities of daily living is one of the goals of VR-therapy. For example, it is possible to train for dangerous situations in VR rather than in real life, like crossing a street. A safe environment can allow potential learning opportunities that could not be possible otherwise. VR offers the chance to learn new motor strategies, to relearn motor abilities and aims to improve neural plasticity. (3, 12)

Recent studies have shown a positive effect on upper limb function as well as on activities of daily life. Especially in addition to standard therapy, VR application offers a further way to increase overall therapy time.
An enriched environment can also provide people suffering from a stroke with opportunities to solve problems and master new skills. Higher numbers of repetitions can be reached through interesting, motivational and enjoyable VR tasks.
Using a head-mounted display can even allow the training of both near and far spatial neglect. (2, 11,13, 14)

Areas of VR therapy

VR therapy emerged as a valuable approach to stroke rehabilitation to train cognitive and motor activities.
Multimodal stimuli are used in VR therapy and cognitive rehabilitation. Exploring and neglect training, as well as executive function training or memory training, can be applied in VR.  Improving muscle tension, muscle strength and range of motion are some functional gains as studies have shown. (3, 14, 15, 16)

Are there any limitations?

VR technology is available on the open market and is not specially marked as a medical device per se. Applications/programs on a head-mounted VR device used in the medical field, on the other hand, often need to be approved as medical devices, to be used in clinics or for studies.

There are some commonly known potential risks using VR such as motion sickness or vertigo. Often they occur in complex and motion intensified applications. For some patients with cognitive deficits, VR could be overwhelming, distracting and create a cognitive overload rather than act as training. (10, 12)

Another potential limitation could be the lack of transference into an actual activity of daily life. That would mean a visual training effect but no or only little improvement in daily life. (17)

How rewellio works with VR 
Rewellio launched its stroke rehabilitation application on the Oculus Quest VR headset.
The Oculus Quest is an affordable and all-in-one solution that changes the extensibility of VR.

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By implementing known therapy strategies, we at rewellio want to create an environment that challenges and motivates our patients to reach even higher.
Rehabilitation is often hard, sometimes you need a push form your family or caretaker but it doesn’t have to be boring.

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Bibliography

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    2. Laver, K. E., Lange, B., George, S., Deutsch, J. E., Saposnik, G., & Crotty, M. (2017). Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews, 80(2), 57–62. https://doi.org/10.1002/14651858.CD008349.pub4
    3. Lee, H. S., Park, Y. J., & Park, S. W. (2019). The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic Review and Meta-Analysis. BioMed Research International, 2019, 1–12. https://doi.org/10.1155/2019/7595639
    4. Ogourtsova, T., Souza Silva, W., Archambault, P. S., & Lamontagne, A. (2017). Virtual reality treatment and assessments for post-stroke unilateral spatial neglect: A systematic literature review. Neuropsychological Rehabilitation, 27(3), 409–454. https://doi.org/10.1080/09602011.2015.1113187
    5. Huber, T., Wunderling, T., Paschold, M., Lang, H., Kneist, W., & Hansen, C. (2018). Highly immersive virtual reality laparoscopy simulation: development and future aspects. International Journal of Computer Assisted Radiology and Surgery, 13(2), 281–290. https://doi.org/10.1007/s11548-017-1686-2
    6. Izard, S. G., Juanes, J. A., García Peñalvo, F. J., Estella, J. M. G., Ledesma, M. J. S., & Ruisoto, P. (2018). Virtual Reality as an Educational and Training Tool for Medicine. Journal of Medical Systems, 42(3), 50. https://doi.org/10.1007/s10916-018-0900-2
    7. Bernardo, A. (2017). Virtual Reality and Simulation in Neurosurgical Training. World Neurosurgery, 106, 1015–1029. https://doi.org/10.1016/j.wneu.2017.06.140
    8. Ekstrand, C., Jamal, A., Nguyen, R., Kudryk, A., Mann, J., & Mendez, I. (2018). Immersive and interactive virtual reality to improve learning and retention of neuroanatomy in medical students: a randomized controlled study. CMAJ Open, 6(1), E103–E109. https://doi.org/10.9778/cmajo.20170110
    9. Stepan, K., Zeiger, J., Hanchuk, S., Del Signore, A., Shrivastava, R., Govindaraj, S., & Iloreta, A. (2017). Immersive virtual reality as a teaching tool for neuroanatomy. International Forum of Allergy & Rhinology, 7(10), 1006–1013. https://doi.org/10.1002/alr.21986
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    11. Keshner, E. A., & Fung, J. (2017). The quest to apply VR technology to rehabilitation: tribulations and treasures. Journal of Vestibular Research, 27(1), 1–5. https://doi.org/10.3233/VES-170610
    12. Dockx, K., Bekkers, E. M., Van den Bergh, V., Ginis, P., Rochester, L., Hausdorff, J. M., … Nieuwboer, A. (2016). Virtual reality for rehabilitation in Parkinson’s disease. Cochrane Database of Systematic Reviews, (12). https://doi.org/10.1002/14651858.CD010760.pub2
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