Evidence Review of Virtual Reality in Rehabilitation
My name is Rohini Kumar, and I am a physiatrist here at Cooper, and will be discussing evidence review of virtual reality. I have no financial disclosures.
Like Dr. Jovin had mentioned, the REAL System found us and asked us to help in the research and development during the beta phase of testing. So we were able to see the device and understand its application.
So my role at Cooper, I am an assistant professor at our medical school and I am a consultant at Cooper. We do not have an inpatient rehab floor, however I spend about 75% of my time doing inpatient consults and 30% of my time doing outpatient services. For those of you who may know or not know, physiatrist, we can help with musculoskeletal deficits, doing joint injections, trigger point injections, EMGs, acupuncture and we are here to help in terms of functional recovery and coordination of care. I went to medical school at Jefferson and graduated in 2007. I completed my residency at Temple University and where I was lucky to work at Moss Rehab and graduated in 2011 and I have been here at Cooper ever since graduation from residency.
Dr. Jovin touched on all the highlights of Cooper, but I’ll just mention again in case we have some latecomers. We are a tertiary care medical center. We have our own medical school, we are a Level 1 Trauma Center and Level 2 Pediatric Trauma Center. We were able to work with MD Anderson Cancer patients, I have a special interest in working with post-mastectomy patients, helping to regain function after their treatments throughout the cancer spectrum.
We received our comprehensive stroke certification in 2016, we are part of the neurologic institute as well as the bone and joint institute.
So we stay quite busy with our patients. We have a diverse collection as you can imagine, being a level one trauma center, we have the opportunity to work with traumatic brain, spinal cord, stroke, amputee, the wide variety of cancer patients, multiple joint replacements and the medically complex patient either cardiac, pulmonary, GI, renal and every organ system. So we have the deconditioned patient, we have patients that have significant upper motor neuron deficits, upper extremity and lower extremity, gait deviations, speech pathology, you name it, and we have that deficit here.
Now the average American is supposed to exercise 15 minutes per day, and that’s a healthy individual. For the rehab patient, we know that three hours per day is what that individual will need. And that can be during the acute phase, subacute and chronic phase of their injury. And so you can imagine that these patients are going to be in a marathon. You wouldn’t start a marathon without training for the marathon. So these patients that require a lot of rehabilitation, are the individuals that we hope to be able to help, and we moreso saw the REAL System with our stroke patients, but it has the potential to be applied to other neuromuscular deficits.
We have a large team of therapists, like I said we’re not an acute rehab hospital, however we have multiple therapists that go bedside or bring patients to the physical therapy gym. We have wonderful therapists that help daily mobilizing patients and assisting in all aspects of functional mobility.
Our speech therapists are wonderful in helping with dysphagia, aphasia, dysarthria, higher-level communication deficits, and so we have a fantastic team in our hospital as well.
Now when we talk about neurorehabilitation, there are multiple challenges. There are significant deficits as I had outlined, each category of patient will have weakness, either upper, lower extremity, they will have gait deviations, they will have core instability, language deficits, so there are a lot of problems that we can focus on but there are just not enough hours in the day and not enough therapists to provide three hours of therapy in our setting.
The other difficulty that we face is that there could be a delay in getting the patient from the acute care hospital side into the acute patient rehab. And we do not want to miss the open window of opportunity. For myself I became interested in virtual reality after hearing a lecture by Dr. John Krakauer of Hopkins University in which he discusses the concept of neuroplasticity. And he highlights a crucial window that he labels as hyperplasticity, very close to the onset of the stroke. Once the patient is stabilized, then we should be delivering early and intensive rehab at that time, because during the hyperplasticity phase is where patients have the most potential to get back to their baseline. Sometimes patients will spend their time in isolation, in a room without interaction from anyone, and this is where we see the opportunity for virtual reality to help us during the acute phase, where the patient has the large potential for recovery.
So technology can be used with some of these core principles of neurorehabilitation. For therapies to be effective, it has to be a goal-oriented task. It has to have a purpose that translates into a functional activity of daily living.
Technology would allow us to increase the number of repetitions. Patients require hundreds if not thousands of gross motor movement to regain the neural network and improve the neural connections, as we know, Hebb’s Law: neurons that fire together, wire together. So we need a huge dose and we need a lot of repetition in order to make these skills transferable and learned.
Virtual reality can give us the opportunity to have variable practice and modify the intensity to the patient’s current needs in their capacity. There are also intrinsic and objective reward systems using virtual reality. Virtual reality can give us an opportunity to give feedback both to the patient as well as the therapist in tracking movements and functional improvements.
Virtual reality gives us a new, enriched environment in which patients can be more transported from focusing on their deficit into a different world and it can be more playful, and more stimulating and engaging, both sensory and motor cortices.
There are a few systems, I just wanted to touch base and differentiate immersive versus non-immersive. The REAL System is an immersive system, meaning the patient would wear a headset and they’d see a 360-degree view of a virtual environment that they can be transported into. Non-immersive is that there is no head device, it is a screen in front of the patient and their peripheral vision is open, so that they are able to see their surroundings and hear different sounds.
In the VR System with the REAL System, when you mount the head device, the patient can be fully immersed in and see this new world. It’s a safe environment and everywhere they look they will see their virtual environment. They will see their body represented as an avatar, with the application of the sensors which we’ll get into shortly.
The concept here in seeing an avatar is to take the concept of mirror therapy and apply it so that a patient, when they see their paretic limb move, it activates the contralateral motor cortex and mirror therapy helps to engage the patient, giving them more confidence that they are moving, meaning that if it’s a skydiving activity, then the patient would never do that after a stroke. However, in the virtual environment, they can engage in very unique settings, that allow them to have play-based experiences engaging them, stimulating them and motivating them.
So the REAL System, Immersive System, was developed with healthcare in mind. It was specifically designed to help patients in stroke recovery.
It is FDA approved for upper extremity exercises in the seated position, and they would be supervised by a medical professional.
I’m going to play this video.
So you can see the REAL System.
It is very easy to transport and take to the patient’s bedside, or bring the patient to the gym. These white sensors are applied, they can be cleaned per patient and the black straps are individualized to the patient. There’s objective progress tracking, so the therapist can observe the functional games and the movement on the command center or the therapy pad to the right.
The therapist can adjust the settings and customize it to the patient’s likes, so when patients are involved in rehab we get to know them quite personally, understanding their hobbies, and if we can find exercises that engage them more, they will be more interested in participation, more interested in adherence, and this system allows for changing the intensity and allowing people to engage more actively.
Like I said it’s a portable system, it’s very easy to set up and it can be taken to the bedside or the patient can be brought to the system.
Now let’s get into a little bit of the clinical evidence. We’re gonna look at these three research articles, and the main concept is that adding virtual reality to conventional therapy can lead to better outcomes than just conventional therapy alone.
Laver, et al. in the Cochrane Database review in 2017. This is the large collection of small randomized controlled trials. 72, some had low-quality, some were moderate-quality and in total there was 2,470 participants. The studies were broken into virtual reality alone, control groups that had no therapy, control groups that had standard care therapy, and then the intervention group that received virtual reality in addition to usual care.
So that I’d like to say that using virtual reality alone there was no difference in the patients’ functional outcome. But more so with the research that is taking place. There is more evidence to show that adding virtual reality in addition to conventional therapy is where we can see the difference in functional outcomes. Because we are increasing the dose of therapy we have. The important concept is that we are giving patients more time, early, and the earlier the intervention, the better their outcome and potential to get back to their baseline.
So in the methods section, it was a systematic review, and we had a meta-analysis, looking at randomized controlled trials of virtual reality based interventions. And this included VR systems specific to a neurodeficit and off-the-shelf gaming systems.
The major two findings in upper limb function was that VR used in addition to conventional therapy, giving you a higher dose of therapy is where we gain a benefit. And the combination of VR with conventional had a statistically significant improvement in the ADLs compared to conventional therapy alone, and that was in the Fugl-Meyer score, which is a quantitative measure assessing motor recovery in stroke patients.
Kiper et al. is the next study that we’ll discuss. It was a randomized controlled trial. It was based in a hospital that was an intense rehab unit with 136 stroke patients. It excluded patients that had severe cognitive impairments, neglect, apraxia and sensory disorders.
In the experimental group, there was a combination of reinforced feedback in the virtual environment, with conventional rehab, while the control group only received conventional therapies. And the time frame was both received two hours of therapy daily, five days a week and for four consecutive weeks.
The difference they tracked was a Fugl-Meyer upper extremity score and the FIM score. The Fugl-Meyer score for the reinforced virtual reality showed a difference of 14.77 percent, compared to 4.55 percent. In the control group, the FIM score showed a difference of 9.5 percent and compared to the control group of 6.9 percent. There was no statistical significance in the NIH score or the ESAS score, but there was a difference in the kinematic parameters.
So in this study they looked at the duration of how quickly patients completed a task and that was statistically significant. There was an improvement in the time spent during therapy.
The speed at which the task was completed also improved, and the number of submovements that is the peak.
So functional and kinematic outcomes improved in both groups after treatment but the group with only conventional was lower than the reinforced feedback group. And the reinforced feedback group was effective in both ischemic and hemorrhagic strokes.
To reiterate, the Fugl-Meyer score gained 4.77% in the control group, while it was a significant improvement in the virtual reality group with the reinforced feedback of 14.73%.
Turolla et al. had a different approach, but with the same time frame. Turolla noticed that 80% of stroke patients had an upper extremity functional deficit, and though 30 to 40% of those patients improved at the 6-month mark, 66% still had a functional deficit in terms of performing their ADLs, so this affects their life-long quality.
In this study it was a single arm prospective study with 376 stroke patients. The experimental group, again was reinforced feedback with the virtual environment compared to upper limb conventional therapy. And the control group had upper limb conventional therapy alone.
The time frame was two hours a day, five days a week, and four weeks in total.
The measurements looked at again Fugl-Meyer score which is the quantitative assessment after a stroke recovery, and in the motor impairment scores, they divided it based on the Fugl-Meyer, in the group less than 20, there was a 5% improvement in the conventional therapy, while there was 11% improvement in the reinforced feedback group.
In the middle group, there was again only 5% for the conventional therapy, with 14% increase in the Fugl-Meyer score in virtual reality. And for the third group, there was only 3% in the conventional therapy while there was an 8% improvement in the virtual reality.
This study also looked at when was the patient going to rehab, the stroke to rehab interval, from the time of the stroke all the way up to one year. There was only in each category from less than three months to the year, only 4% improvement in all subgroups, but with the virtual reality reinforced feedback, 13% improved at the early stage, 10% improved in the subacute phase, and 7% improved in the chronic phase.
So again in summary, there was an improvement in the Fugl-Meyer score and FIM score combining virtual reality with conventional therapy than therapy alone.
This graph shows that both groups in Kiper et al. and Turolla et al. received two hours of therapy daily, for five days a week and for four weeks. And for the same amount of time, combining virtual reality led to a better outcome than conventional therapy alone.
Maier et al. looked at off-the-shelf gaming systems and virtual reality systems that were particularly designed for rehab. It was a meta-analysis of 30 randomized controlled trials. 1,473 patients were included and it was a systematic search for randomized control with adult strokes to analyze effects of specific VR systems versus non-specific VR systems versus conventional therapies.
This specific VR system was designed for the rehab patient and non-specific were off-the-shelf gaming systems.
In the specific VR group, they showed a significant impact in the upper limb function which was superior to conventional therapy alone. Both in terms of function as well as improvement in their activities of daily living.
While the non-specific VR group, the off-the-shelf gaming systems did not show a significant effect in the function of the activity.
Specific VR systems can tap into 11 principles of neuro-rehabilitation. So I’m gonna go through these and highlight how we see differences in the recovery of a patient.
So it is the number of repetitions that are performed that can improve the patient’s retention of the information. The more dose, more than five hours per week, can improve the functional recovery. And if someone has structure practice training through frequent and longer sessions, there is better retention and neuroplasticity. If it is a task that is specific, it translates into learning something that can be used as a goal or an ADL.
There’s variable practice, meaning that the patient can be challenged in their intensity or in the relevant side of their deficit. So that the patient does not succumb to learned disuse.
Virtual reality can use a multisensory stimulation, with visual, audio and a feedback system that patients would be able to see their performance and get the intrinsic and reward of completing a task.
There is the avatar which represents the patient through the sensors and the patient can see their reflection, their paretic limb moving, that is very motivating for the patient as well as again tapping into near-base therapies and reflective practices.
The main goal of any therapy is to promote using the affected limb, and if you are forced to use the limb without thinking about it, there is a better chance of recovery and improving the outcomes.
Specific virtual reality systems use more than six of these principles, while non-specific off-the-shelf gaming systems only used three of the practices.
Now in conclusion, I wanted to reiterate that when you take virtual reality and you add it to conventional therapy, that is where we see an improvement in motor function, in the activities of daily living, when it is compared to just therapy alone. And you can improve the upper limb function and in the same amount of time, that’s an impressive outcome that you will have upper limb movement improvement motor scores in the Fugl-Meyer and FIM scores for that same specific amount of time.
VR systems that are designated for rehab are more effective than off-the-shelf gaming systems because they tap into the principles of rehabilitation being task-oriented, goal-oriented, motivating, engaging, stimulated multi-sensory and improving patient engagement.
And the main features that we have seen are motivation and feedback, is what enhances the patients to stay compliant for the long-term.
With that I’m done and I will hand it off to Mr. Owens.
Video recording used with permission. Consent on file at Penumbra, Inc. The opinions and clinical experiences presented herein are for informational purposes only. The results may not be predictive for all patients. Individual results may vary depending on patient-specific attributes and other factors. Any treatment decision must be made in consultation with a healthcare provider based on a complete discussion of risks and benefits. The views and opinions expressed herein are those of the presenter and do not necessarily reflect the views of Penumbra, Inc. or its ailiates. The featured presenter is consultant for Penumbra, Inc.
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