Virtual Reality in Your OT Practice

I think we can safely assume that we are only beginning to see the potential that VR has for transforming occupational therapy (as well as physical therapy and speech therapy.)  

There are whole societies that OTs can join, focused on the use of virtual reality (VR) in rehabilitation (like the International Society for Virtual Rehabilitation).  New VR technologies and applications seem to be emerging almost daily.  

Whether you are interested in incorporating virtual reality into your therapy practice, are a self-proclaimed “techie” or are just interested in glimpsing the future, this article is for you.

 The post features:

• What the research says about VR and OT
• Therapy focused VR that is currently on the market
• Discussion of product development and VR research that is in the works

Technology as Occupation: Why VR?

Technology is not only a means for occupation, including how we work and relate to each other, but is also the target of our occupation now more than ever before.  As a human race, technology consumes a great deal of our occupational behavior.  Why?  We are engaged, connected and rewarded through technology.  

A number of studies over the last decade and a half have revealed that game playing triggers dopamine release in the brain, a finding that makes sense, given the instrumental role that dopamine plays in how the brain handles both reward and exploration.  Virtual reality (VR) activities rooted in games or ADL tasks with a distinct aim, reinforce voluntary repetition, which is a key ingredient for motor recovery based on principles of neuroplasticity.  

Another benefit of virtual reality therapies is that patients can be engaged in a high dose of therapy or repetition early on in their stroke recovery, taking advantage of the window where cortical reorganization is at its peak.  For children with neuromuscular challenges like CP, since technology and gaming has become second nature for many in the youngest generation, children may not even recognize that they are participating in rehabilitation through virtual reality.  

What the Research Says About VR and Therapy

The literature shows that engagement in graded, appropriately dosed and task-oriented practice are contributors to upper limb improvement and cortical reorganization (Timmermans et al, 2010).

In traditional occupational therapy sessions focused on upper limb improvement post-stroke, research shows that only 23 to 32 repetitions are completed in a standard session (Kimberly et al, 2010).  This is far fewer than is necessary for motor improvement.  In addition, during sub-acute stroke rehab, an average of 4 minutes are spent on task-specific upper limb training in a typical session (Hayward & Brauer, 2015).  In comparison, virtual reality interventions can yield an average of 200-300 functional movements per one hour session (Brunner et al, 2016).

A randomized controlled trial using the Neofect Smart Glove, compared to a control group of “standard occupational therapy” along with use of the VR tool, demonstrated improvement for both the proximal and distal upper extremity on the Fugl-Meyer.  The device is primarily focused on forearm, wrist and hand motion, yet prompted shoulder and upper arm improvement as well as hand, wrist and forearm (Shin et al, 2016).  

This speaks to the engagement in upper extremity task-oriented practice as counteracting the “learned non-use” that many stroke survivors experience.  All participants received a 4-week face to face intervention program that included use of the Smart Glove along with traditional occupational therapy (OT) interventions or traditional OT only.  The dosage of therapy or this study was daily intervention for 30 minutes, five days per week for a total of 20 sessions.  Patients using the Smart Glove also demonstrated improvement in health related quality of life utilizing the Stroke Impact Scale compared to those that did not use the VR intervention (Shin et al, 2016).

Saposnik and Levin (2011), in a review of twelve VR approaches, reported that eleven of the twelve virtual systems showed significant benefit in the selected outcome measure.  In an assessment of the use of virtual environments for stroke rehab, Holden (2005) noted that improvement in motor function appears to translate to real life tasks.  A comparative investigation of an intervention in a real-life environment versus in a virtual environment, yielded nearly equivalent improvements in motor function (Subramanian et al, 2013).

What VR is Currently Available for OTs?

Virtual reality technology is quickly evolving.  Here is a short list of accessible Virtual Reality devices that can be used in your practice:

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Neofect

Rapael Smart Glove and Smart Kids (Pediatric Version)

Description: Smart Glove is a lightweight, silicone exo-glove that interacts with tablet using bluetooth technology.  SG has an assessment mode to track changes in AROM and PROM as well as coordination and timing.  Employs artificial intelligence to change parameters of activities for “just right challenge”.  Even with a small amount of activation, a patient can be successful with the device.  

Tasks Involved: Challenges wrist, digit and forearm motion.  Includes activities such as, catching balls or butterflies, squeezing oranges, fishing, cooking, cleaning the floor, pouring wine, painting fences, and turning pages along with other more novel and complex games.  There are also games that target visual and cognitive processes.

Minimal Motion Required: Minimal activation of the forearm (supination/pronation) and wrist (flexion/extension) or digits is needed for best success.  The device does not provide active assistive motion.

Research Support: Randomized controlled trial demonstrates improvement of distal and proximal items on Fugl-Meyer and Jebsen-Taylor as well as quality of life on the Stroke Impact Scale.

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Flint Rehabilitation

MusicGlove

Description: Music Glove is a glove with finger sensors to work on timing of finger motion and fine motor control.

Tasks Involved: Opposition of digits to thumb coordinated to music to improve coordination and timing.  Interface looks like “guitar hero”, encourages the patient to make contact to the beat.

Minimal Motion Required: Lateral pinch is required for successful participation.

Research Support: Music Glove users demonstrated Improvement in box and blocks scores over controls.

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Flint Rehabilitation

FitMi

Description: FitMi consists of “pucks” that interact with therapeutic exercise apps on Flint Tablet, PC or Mac.  The apps are designed to target hand, arm, trunk and leg impairment.

Tasks: RehabStudio regimens can be created from a library of 40 classic exercises.  Real-time visual, auditory and repetition feedback is provided and tracked.

Minimal Motion Required: Puck can either be handheld or on a tabletop for targeted reaching to full UE ROM.  

Research Support: New product, limited published research support at this time.

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Saebo

SaeboVR

Description: SaeboVR is a virtual ADL (activities of daily living) rehabilitation system. The proprietary platform was specifically designed to engage the client in both physical and cognitive challenges involving daily functional activities.

Tasks: SaeboVR‘s ADL-focused virtual world provides clients with real-life challenges. Users will incorporate their impaired upper limb to perform simulated self-care tasks that involve picking up, transferring and manipulating virtual objects.

Minimal Motion Required: The program detects movement but does not assist with mobility.  A mobile arm support or other assistive device can be used for UE support.

Research Support: Patients engaged in the Saebo VR therapy demonstrated improvement on Fugl-Meyer measures with an average of close to 200 motions per session.

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 The Future of VR and Rehab

Scott Kim, CEO of Neofect, the makers of the Rapael Smart Glove and Smart Kids, has seen patients engage with the device unlike other previous rehabilitation options. He is seeing therapists also find growing value in its use as a rehabilitation tool.  “The more efficient the therapists are, the more they can do their work to best reach the patients.  There is so much more to be learned, discovered, and taught as it relates to neuro-rehabilitation.  The more tools that we can get into the hands of therapists focusing on neurological conditions, the more opportunities for us as a company to learn from them and their experience (S. Kim, personal communication, Nov 13, 2016).”  Neofect has a couple of other developments on the horizon including a Smart Board to encourage shoulder and other upper extremity functions in a virtual reality environment as well as a Smart Pegboard with visual and cognitive components for a multi-sensory rehab experience. The Smart Board launched in June of 2017 and the Smart Pegboard is slated to be released in September of this year.   

Upper extremity rehabilitation is often delayed in the acute phase of rehab due to the need for medical stabilization and other priorities.  How might VR change the timing of intensive UE rehabilitation post-stroke?  MindMaze, a company headquartered both in Silicon Valley and Lausanne, Switzerland is attempting to answer that question.  Primary clinical results suggest that their technology, which consists of a motion sensing camera and an avatar of the patient on a screen, can increase the number of repetitions of UE movement by 60% in 10 sessions, improving patient efficiency early in the rehabilitation process (Chevalley et al., 2015).  The company’s main product, currently commercially available in European markets, is the Mind Motion Pro.  Its main goal is to provide patients with an immersive experience early on in their rehabilitation to capitalize on early upper extremity training.  The device can be wheeled up to the patient’s bedside and lets the patient begin to train using mirror preparation with the unaffected limb right away post-stroke.  This helps to minimize downtime in the acute care and inpatient rehabilitation units.  Patients have been shown to be able to participate as early as 4 days post stroke for an average of 20 minute sessions to start upper limb training early on in the rehab process (Kinzner et al, 2015).  

Dr. Karen Kerman, Chief Medical Officer of MindMaze, is encouraged by the reception of virtual reality devices in the medical community.  “The goal of virtual reality and of the Mind Motion Pro, for example, is not to replace the therapist with technology but to provide motivation to the patient and free the patient up a bit as they are tasked to do more within a rehabilitation environment (K. Kerman, personal communication, Dec 17, 2016).”  MindMaze aims to create products throughout the continuum of care as well, training a patient on a device in an outpatient setting that they would have access to at home.  The Mind Motion Go, not yet commercially available in the US, is a portable tabletop unit where the patient plays a series of games to address the wrist, arm, and shoulder using a virtual environment.  While the device doesn’t eliminate compensatory movement, it gives real time feedback, an important hallmark in task-oriented practice.  

Beta testing is currently occurring in the US and Europe to get therapist feedback on the device and clinical trials.  MindMaze is seeking to receive feedback from therapists that are technologically savvy as well as those that may not be as comfortable with technology. In doing so, MindMaze hopes to close the gap that some patients experience in regards to an OT’s comfort level with technology driving whether or not they choose to engage a patient with such devices.  

“There is a great future in the area of virtual reality and neuro-rehabilitation.  There are patients that have grown up with technology, they interact socially using technology, and they use it to do their work.  We hope that MindMaze technology can allow stroke patients to have a social network to work with and engage in game play.  The technology provides a social connection during this sometimes disconnected experience.  Clinically, We want to increase the number of repetitions and compliance in an enjoyable gaming experience and we hope that this is a gateway to better functional performance for patients,” Dr. Kerman notes.  “If we can motivate and engage patients with games, we hope patients will work harder and feel less isolated overtime.  Our hope is not only to improve the number of rehab sessions, but to customize it overtime so that patients can reach their maximum potential (K. Kerman, personal communication, Dec 17, 2016).”  

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Have you utilized VR in Your OT Practice? What questions do you have about VR (that we could possibly answer in updates to this post?) Please share in the comments below! 

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About the Author

Lauren is celebrating her 10th year as an occupational therapist in 2017.  Her dream to join a technology company was realized when dreaming about the possibility of doing something “outside the box” after spending the last decade in outpatient neuro clinical practice and most recently in administration and management roles.  Lauren has served in various roles on her state occupational therapy associations and is a proponent of being an active member, particularly in advocating for occupational therapy through legislation and contact with elected officials.  She has enjoyed planning and organizing Washington state’s “Hike the Hill” event for the last three years.  She is also currently serving as the AOTA Representative Assembly Member for the state of Washington.  

Lauren has published multiple articles with OT Practice and is excited to be back to writing, starting with OT Potential, in this new intersection of neuro-rehab, OT and virtual reality.  Lauren believes that OT professionals are poised to be product designers, user experience experts and consultants as it relates to technology solutions that meet the needs of individuals with disabilities.  

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References:

Brunner, I., Skouen, J.S., Hofstad, H., Abmuss, J., Becker, F.,Pallesen, H., Thijs, L., Verheyden, G. (2016). Is upper limb virtual reality training more intensive than conventional training for patients in the subacute phase after stroke?: An analysis of treatment intensity and content. BMC Neurology, 16: 219, DOI: 10.1186/s12883-016-0740-y

Chevalley, O., Schmidlin, T., Perez-Marcos, D., Garipelli, G., Leeb. R., Duc, C., Vollen, R., Marchand, C., Vuadens, P., Tadi, T., Blanke, O., d.R. Millán, J.  Improved Upper Limb Motor Control with Intensive Virtual Reality Training in Chronic Stroke, European Congress for Neurorehabilitation, Vienna 2015.

Hayward, K. S., & Brauer, S. G. (2015). Dose of arm activity training during acute and subacute rehabilitation post stroke: A systematic review of the literature. Clinical Rehabilitation, 29(12), 1234-1243. doi: http://dx.doi.org/10.1177/0269215514565395

Holden, M. K. (2005). Virtual environments for motor rehabilitation: Review. Cyberpsychology & Behavior : The Impact of the Internet, Multimedia and Virtual Reality on Behavior and Society, 8(3), 187-211; discussion 212-9. Retrieved from https://search.proquest.com/docview/67962132?accountid=143111

Kimberley TJ, Samargia S, Moore LG, Shakya JF, Lang CE. Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke. J Rehabil Res Dev. 2010;47(9):851-62. DOI:10.1682/JRRD.2010.02.0019

Kinzner, H., Garipelli, G., Perez-Marcos, D., Tadi, T., Diserens, K. Virtual Reality Based Upper Limb Neurorehabilitation in Acute Stroke: A Single-Case Study, 45th annual meeting of the Society for Neuroscience, Chicago, IL, USA, 17-21, October, 2015.

Mindmaze SA. Study evaluating the MindMotionPRO for early post-stroke upper-limb rehabilitation (MOVE-Rehab).  In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [citied 2017 Jan 14]. Available from: https://clinicaltrials.gov/ct2/show/NCT02688413. NLM Identifier: NCT02688413

Saposnik, G., Levin, M., & Outcome Research Canada (SORCan),Working Group. (2011). Virtual reality in stroke rehabilitation: A meta-analysis and implications for clinicians. Stroke, 42(5), 1380-1386. doi:http://dx.doi.org/10.1161/STROKEAHA.110.605451

Shin, J., Kim, M., Lee, J., Jeon, Y., Kim, S., Lee, S., Seo, B., Choi, Y. (2016). Effects of virtual reality based rehabilitation on distal upper extremity function and health-related quality of life: a single, blinded, randomized controlled trial. Journal of NeuroEngineering and Rehabilitation, 13, 1-17.

Subramanian, S. K., Lourenço, C.,B., Chilingaryan, G., Sveistrup, H., & Levin, M. F. (2013). Arm motor recovery using a virtual reality intervention in chronic stroke: Randomized control trial. Neurorehabilitation and Neural Repair, 27(1), 13-23. doi:http://dx.doi.org/10.1177/1545968312449695

Timmermans, A., Spooren, A., Kingma, H., Seelen, H. (2010). Influence of task-oriented training content on skilled arm–hand performance in stroke: A systematic review. Neurorehabilitation and Neural Repair, 24(9) 858–870.