The home use of virtual reality games in rehabilitation of stroke patients

Authors: Ioana Stanescu, Oana Vanta

Keywords: stroke rehabilitation, immersive 3D game, remote physical therapy

Focus keyword: virtual reality  games

Introduction – the home use of virtual reality games in rehabilitation of stroke patients

Stroke remains the leading cause of long-term disability worldwide. Half of stroke patients survive with various degrees of disability [1]. Population ageing and recent efficient treatments for acute stroke have modified the profile of stroke patients, decreasing mortality rates with increased disability in survivors. Long-term post-stroke disabilities could be physical or cognitive and are aggravated in older patients by age-related problems. Rehabilitation is the specific treatment method dedicated to disability improvement [2]. 

For more information on stroke rehabilitation, visit:

• Efficacy of mirror therapy in the recovery of severe hemiparesis after stroke
• Recovery of precise hand movements after stroke
• Neurorehabilitation therapies after stroke – what therapies are available?

Which are the main features of an efficient rehabilitation program?

Stroke rehabilitation includes methods that aim to improve the affected neurological function and relearn new modalities of compensation for the lost functions. Neurological functions mainly affected by stroke are motility, gait, speech and language, coordination, swallowing and sensibility. Some therapies delivered in stroke rehabilitation are described in Fig 1 below.

Figure 1. Therapies in stroke rehabilitation

An effective rehabilitation program should:

• start early, as soon as the neurologic condition of the patient is stable
• have a high intensity: between 5 to 10 hours a week for at least 12 weeks
• have a long duration–(6 to 12 months after stroke), as improvements have been also demonstrated in patients with chronic stroke [2–3].  

Are there any limitations to long-term rehabilitation? Which are the solutions? 

There are a few barriers to continuous rehabilitation training for stroke patients:

• Accessibility: Patients generally receive outpatient rehabilitation in subacute and chronic phases after stroke.   
  • Distance and transportation are problems for stroke patients involved in training programs in outpatient rehabilitation centers. 
  • Therapist availability is a problem for patients receiving home-based training. 

Solution: a rehabilitation program that could be delivered at home, without supervision [2].  

• Habituation After weeks of intense training, some patients drop out of the rehabilitation program because of exhaustion or boredom. 

Solution: the development of more interesting and attractive programs (e.g., games) in which stroke patients are more easily involved. 

How is VR training useful for home-based rehabilitation? 

Many studies showed that using virtual reality (VR) techniques in stroke rehabilitation has increased patient adherence and training efficacy. VR provides a more enjoyable way to continue the rehabilitation program. Moreover, gamifying physical therapy using computer games will make rehabilitation sessions more attractive for patients. 

The benefits of virtual reality therapies are mentioned in Figure 2 below: 

Figure 2. Benefits of VR Therapies

With these advantages, VR therapies are an alternative to one of the most efficient treatment methods – Constraint-Induced Movement Therapy.

A new prototype for Virtual Reality games using a tri-dimensional (3D) environment?

Many research groups have developed different systems providing VR training specifically for stroke patients.

Korean authors and Microsoft have developed an interactive prototype that tracks patient movements and adjusts accordingly to program difficulty. The system offers social-media interactions for stroke patients [3]. Another group of authors developed a prototype in which the patient uses two gloves to row a virtual boat- one to inhibit hand movements on the unaffected side and the other to facilitate and track hand movements on the paretic side [4].  

Kaminer and his group developed a system that provides a 3D environment in which the patients should fully emerge to accomplish different motor tasks [3]. The game player will perform movements to accomplish tasks on the screen inspired by physical therapy exercises.

What are the components of the system? 

The system is comprised of: 

1. The game software.  
2. A pair of haptic gloves →  control hand and finger animation movements
3.  A Kinect system (motion-sensing device developed by Microsoft) →  controls the avatar’s movement.
4. An Oculus Rift → provides the screen for the game and the camera orientation. The Oculus Rift is an immersive google for VR.

How does the system work?

The different components of the system take specific roles:

•  The gloves contain sensors to capture the pressure and finger movements. While the patient is moving the hand and the fingers, the bend sensors record all the movements and help the patient operate and control his in-game virtual hands. The therapist uses the data collected to document the progress in upper limb mobility. 
• The Kinect can detect the posture and movements of a patient’s body and recognize body gestures in real time. Tracking patient body movements allows therapists to assess motor deficits and their improvement during therapy [3, 5]. 
• The Oculus Rift provides the screen for the game and the camera orientation

The data collected by Kinect, gloves and Oculus Rift are analysed by the software and used to assess patient motility function and refine the tasks for the patient’s next playing sessions. Data analysis will reconstruct patient movements and draw a specific outline of the avatar. According to his data analysis, each patient will receive an individualised training plan. The components of the data collection software are shown in Figure 3.

Rehabilitation by 3D computer games: a new perspective for stroke patients?

The games which are using immersive physical exercises focus on motor tasks provided during game scenes. The patient is represented in the game by an avatar (his virtual character) whose movements mimic his actual body movements during different actions. The task consists in reaching and grabbing different cylinders. Also, specific instructions are given to the player during the game [3]. 

The prototype has been tested by only one stroke patient, with good results on usefulness and accessibility. 

What are other alternatives?

Other alternatives for patients with stroke who wish to perform VR training are [6–7]:

• Virtual Reality Games: increase patients’ motivation, optimism and self-confidence 
• ‘punch the boxer’: the patient is fighting with the avatar of a virtual boxer on the screen; the patient should use his upper limb force, precise movements and coordination, and maintain body balance during the game;
• ‘throw the ball’: the patient has to throw a ball in the mouth of a dragon, an action that requires coordination and precision of hand movements, but also attention because the ball could suddenly explode on its way toward the target.

• Virtual Reality Exercises: will improve muscle strength and body balance, aiming to increase patients’ ability to perform activities of daily living.
• ‘cut the drawing on the screen: the patient is asked to cut with a paper cutter a piece from a virtual drawing on the screen, increasing the precision of its movements;
• ‘close and open the tap’: the patient’s task is to open and close a virtual tap appearing on the screen  

• Virtual Reality: the patient is performing virtual activities, like swimming underwater or climbing mountains, a fully immersive experience. The Journey helps the patient to improve his mood and well-being.   

Conclusion

VR stroke rehabilitation has become the most popular and trending High-tech treatment for stroke patients. This rehabilitation method harnesses the technology of Virtual Reality to monitor patients and improve their receptiveness while performing stroke recovery exercises.

VR training is a computer-based technology where the patient will interact with virtual objects on the screen, improving motor skills and enjoying their time. Some types of VR games allow the immersion of the patient in a controlled environment where multiple stimulations are applied. VR has become very popular in stroke rehabilitation because of its main advantages:

• VR rehabilitation using 3D games is an attractive therapeutic approach for stroke patients 
• Virtual reality games area promising treatment modality easy-to-use for stroke during  home-based rehabilitation 
• Real-time feedback is provided to the patient 
• Repetitive training is allowed
• Enjoyable for all patients

Despite their increased popularity, the confirmation of 3D virtual reality games efficiency in rehabilitation awaits further confirmation in pilot studies and clinical trials.  

References

1. Markus HS. Reducing disability after stroke. International Journal of Stroke. 2022;17(3):249-250. doi:10.1177/17474930221080904
2. Ballester BR, Maier M, Duff A, Cameirão M et al. A critical time window for recovery extends beyond one-year post-stroke. J Neurophysiol. 2019;122(1):350-357. doi: 10.1152/jn.00762.2018. 
3. Kaminer C, LeBras K, McCall J, Phan T et al. An immersive physical therapy game for stroke survivors. Proceedings of the 16th international ACM SIGACCESS conference on Computers & Accessibility.  doi.org/10.1145/2661334.2661340
4. http://www.themarysue.com/stroke-rehab-game/ 
5. El-laithy RA, Huang J, Yeh M. Study on the use of Microsoft Kinect for robotics applications. Proceedings of the 2012 IEEE/ION Position, Location and Navigation Symposium, 2012, pp. 1280-1288, doi: 10.1109/PLANS.2012.6236985.
6. Abdulmajeed W, Hajr A. Controlling Articulated Robot System Using 3D Kinect Visionary Sensor. International Journal of Scientific and Engineering Research. 2015;6(8):477-483, DOI: 10.5281/zenodo.162043
7.  https://www.cognihab.com/blog/virtual-reality-for-stroke-rehabilitation/