Exploring the bases for a mixed reality stroke rehabilitation system, Part II: Design of Interactive Feedback for upper limb rehabilitation

abstract: Background Few existing interactive rehabilitation systems can effectively communicate multiple aspects of movement performance simultaneously, in a manner that appropriately adapts across various training scenarios. In order to address the need for such systems within stroke rehabilitation training, a unified approach for designing interactive systems for upper limb rehabilitation of stroke survivors has been developed and applied for the implementation of an Adaptive Mixed Reality Rehabilitation (AMRR) System. Results The AMRR system provides computational evaluation and multimedia feedback for the upper limb rehabilitation of stroke survivors. A participant's movements are tracked by motion capture technology and evaluated by computational means. The resulting data are used to generate interactive media-based feedback that communicates to the participant detailed, intuitive evaluations of his performance. This article describes how the AMRR system's interactive feedback is designed to address specific movement challenges faced by stroke survivors. Multimedia examples are provided to illustrate each feedback component. Supportive data are provided for three participants of varying impairment levels to demonstrate the system's ability to train both targeted and integrated aspects of movement. Conclusions The AMRR system supports training of multiple movement aspects together or in isolation, within adaptable sequences, through cohesive feedback that is based on formalized compositional design principles. From preliminary analysis of the data, we infer that the system's ability to train multiple foci together or in isolation in adaptable sequences, utilizing appropriately designed feedback, can lead to functional improvement. The evaluation and feedback frameworks established within the AMRR system will be applied to the development of a novel home-based system to provide an engaging yet low-cost extension of training for longer periods of time.The electronic version of this article is the complete one and can be found online at: https://jneuroengrehab.biomedcentral.com/articles/10.1186/1743-0003-8-5

Master of Science

thesisStroke is a leading cause of death and adult disability in the United States. Survivors lose abilities that were controlled by the affected area of the brain. Rehabilitation therapy is administered to help survivors regain control of lost functional abilities. The number of sessions that stroke survivors attend are limited to the availability of a clinic close to their residence and the amount of time friends and family can devote to help them commute, as most are incapable of driving. Home-based therapy using virtual reality and computer games have the potential of solving these issues, increasing the amount of independent therapy performed by patients. This thesis presents the design, development and testing of a low-cost system, potentially suitable for use in the home environment. This system is designed for rehabilitation of the impaired upper limb of stroke survivors. A Microsoft Kinect was used to track the position of the patient's hand and the game requires the user to move the arm over increasing large areas by sliding the arm on a support. Studies were performed with six stroke survivors and five control subjects to determine the feasibility of the system. Patients played the game for 6 to 10 days and their game scores, range of motion and Fugl-Meyer scores were recorded for analysis. Statistically significant (p<0.05) differences were found between the game scores of the first and last day of the study. Furthermore, acceptability surveys revealed patients enjoyed playing the game, found this kind of therapy more enjoyable than conventional therapy and were willing to use the system in the home environment. Future work in the system will be focused on larger studies, improving the comfort of patients while playing the game, and developing new games that address cognitive issues and integrate art and therapy

An integrative framework for tailoring virtual reality based motor rehabilitation after stroke

Stroke is a leading cause of life-lasting motor impairments, undermining the quality of life of stroke survivors and their families, and representing a major chal lenge for a world population that is ageing at a dramatic rate. Important technologi cal developments and neuroscientific discoveries have contributed to a better under standing of stroke recovery. Virtual Reality (VR) arises as a powerful tool because it allows merging contributions from engineering, human computer interaction, reha bilitation medicine and neuroscience to propose novel and more effective paradigms for motor rehabilitation. However, despite evidence of the benefits of these novel training paradigms, most of them still rely on the choice of particular technologi cal solutions tailored to specific subsets of patients. Here we present an integrative framework that utilizes concepts of human computer confluence to 1) enable VR neu rorehabilitation through interface technologies, making VR rehabilitation paradigms accessible to wide populations of patients, and 2) create VR training environments that allow the personalization of training to address the individual needs of stroke patients. The use of these features is demonstrated in pilot studies using VR training environments in different configurations: as an online low-cost version, with a myo electric robotic orthosis, and in a neurofeedback paradigm. Finally, we argue about the need of coupling VR approaches and neurocomputational modelling to further study stroke and its recovery process, aiding on the design of optimal rehabilitation programs tailored to the requirements of each user.info:eu-repo/semantics/publishedVersio

The use and effect of video game design theory in the creation of game-based systems for upper limb stroke rehabilitation

Upper limb exercise is often neglected during post-stroke rehabilitation. Video games have been shown to be useful in providing environments in which patients can practise repetitive, functionally meaningful movements, and in inducing neuroplasticity. The design of video games is often focused upon a number of fundamental principles, such as reward, goals, challenge and the concept of meaningful play, and these same principles are important in the design of games for rehabilitation. Further to this, there have been several attempts for the strengthening of the relationship between commercial game design and rehabilitative game design, the former providing insight into factors that can increase motivation and engagement with the latter. In this article, we present an overview of various game design principles and the theoretical grounding behind their presence, in addition to attempts made to utilise these principles in the creation of upper limb stroke rehabilitation systems and the outcomes of their use. We also present research aiming to move the collaborative efforts of designers and therapists towards a model for the structured design of these games and the various steps taken concerning the theoretical classification and mapping of game design concepts with intended cognitive and motor outcomes

Flexible Virtual Reality System for Neurorehabilitation and Quality of Life Improvement

As life expectancy is mostly increasing, the incidence of many neurological disorders is also constantly growing. For improving the physical functions affected by a neurological disorder, rehabilitation procedures are mandatory, and they must be performed regularly. Unfortunately, neurorehabilitation procedures have disadvantages in terms of costs, accessibility and a lack of therapists. This paper presents Immersive Neurorehabilitation Exercises Using Virtual Reality (INREX-VR), our innovative immersive neurorehabilitation system using virtual reality. The system is based on a thorough research methodology and is able to capture real-time user movements and evaluate joint mobility for both upper and lower limbs, record training sessions and save electromyography data. The use of the first-person perspective increases immersion, and the joint range of motion is calculated with the help of both the HTC Vive system and inverse kinematics principles applied on skeleton rigs. Tutorial exercises are demonstrated by a virtual therapist, as they were recorded with real-life physicians, and sessions can be monitored and configured through tele-medicine. Complex movements are practiced in gamified settings, encouraging self-improvement and competition. Finally, we proposed a training plan and preliminary tests which show promising results in terms of accuracy and user feedback. As future developments, we plan to improve the system's accuracy and investigate a wireless alternative based on neural networks.Comment: 47 pages, 20 figures, 17 tables (including annexes), part of the MDPI Sesnsors "Special Issue Smart Sensors and Measurements Methods for Quality of Life and Ambient Assisted Living

Expanding Rehabilitation Beyond the Clinic—Strategies to Increase Total Restorative Therapy Time for Adults with Hemiplegia

Background: Positive neuroplastic changes involving cortical reorganization after stroke are experience dependent and are facilitated more effectively when rehabilitation occurs with high volume. Structured experiences to promote adaptive changes can be implemented during scheduled therapies in any rehabilitation setting. However, time spent in supervised restorative therapy is limited regardless of setting. Time spent in therapeutic activity can be extended by a variety of options that patients can engage in independently, that are low-cost, and that have evidence to support their use as a supplement to physical and occupational therapy. Purpose: The purpose of this paper is to present four such options for supplemental therapeutic activities to support restorative rehabilitation, including mental practice, mirror therapy, low cost virtual reality, and community group exercise classes. A sample of the evidence supporting their feasibility and effectiveness is presented. Practical guidelines for implementation are provided based on the evidence. Recommendations: Evidence based interventions can be used to extend total restorative rehabilitation time as an extension of therapy activities performed in the clinic. They are feasible and effective and can support positive neuroplastic changes in individuals with hemiplegia. These strategies can and should be implemented across practice settings by physical therapists, occupational therapists, and speech language pathologists

Home-based exergames to improve cognitive function in Multiple Sclerosis: the EXTREMUS Study ​

Background. Motor and cognitive dysfunctions are common and disabling features in multiple sclerosis (MS) that remain challenging to be treated. Exergaming is an emerging tool in neurorehabilitation, which promotes motor functions and fitness level. Evidence in general population and in other neurological conditions suggests that exergames may be beneficial also for cognitive functions, as playing action video games requires the engagement of high-level domains for visuo-motor integration and spatial attention. Objective. To test if home-based exergaming is not inferior to cognitive rehabilitation delivered by a software application (app) for mobile devices and both interventions are superior to a placebo-analogue (sham) cognitive intervention. The hypothesis is that exergames offer a comprehensive approach to improve both motor and cognitive domains. Methods. This is a multicenter, randomized, sham-controlled, single blind, parallel arm study. People with MS (pwMS) will be randomized in a 1:1:1 ratio to receive 1) an 8-week home-based training with exergames, specifically with Nintendo Wii (intervention of interest) or 2) adaptive COGNI-TRAcK (comparator intervention) or 3) sham COGNI-TRAcK (placebo-analogue intervention). Assessments will be conducted at study enrolment (baseline), at the end of the 8-week intervention period (immediate post-training, Week 8) and after 16 weeks from randomization (post-training follow-up, Week 16). At each point in the assessment, Brief International Cognitive Assessment for MS (BICAMS) and the Stroop Color Word Test (SCWT). In addition, pwMS were assessed with the 29-item Multiple Sclerosis Impact Scale (MSIS-29), the 21-item Modified Fatigue Impact Scale (MFIS-21), the 2-Minute Walking Test (2MWT), the Timed Up&Go test (TUG) and by a static posturography under single- (ST) and dual-task (DT) conditions were conducted. Results. Sixty-nine pwMS were assessed for eligibility in this pre-planned interim analysis; of these, 47 were randomized to the three treatment groups. The three treatment groups were comparable in terms of demographic and clinical characteristics at baseline (all p values >0.2). Preliminary analyses show statistically significant results between the SHAM group and the ADAPTIVE group (p=0.04) for the Symbol Digit Modalities Test (SDMT), the information processing speed assessment test that is part of BICAMS; the improvement observed between the EXERGAMES group and the SHAM group, did not reach statistical significance (p=0.06). TUG among the three groups showed statistically significant improvement between the EXERGAMES group and the SHAM group (p=0.01) and the ADAPTIVE group (p<0.001). Regarding fatigue, statistically significant results emerged between the SHAM group and the ADAPTIVE group (p=0.04) and between the ADAPTIVE group and the EXERGAMES group (p=0.01). In the EXERGAMES group, there was an improvement in balance measured by posturography the ST and DT conditions (p=0.01 and p=0.02). Discussion. Although this is only preliminary data, some interesting results emerged from the study. First, both COGNI-TRAcK and Nintendo Wii-treated patients experienced improvements in SDMT compared to the SHAM group. In addition, the study found that patients undergoing home rehabilitation with the Nintendo Wii also achieved improvements in the motor domain. Second, it appears that rehabilitation training with exergames can bring improvements in some specific domains of QoL and fatigue. The results obtained for fatigue in people with MS show that exergames are significantly effective in improving after the intervention, compared with the other groups. These results indicate that rehabilitation with exergames, which requires simultaneous physical and cognitive effort on the part of the patient, promotes not only the strengthening of motor functions, but also the efficiency of brain networks, particularly those dedicated to attention

How a Diverse Research Ecosystem Has Generated New Rehabilitation Technologies: Review of NIDILRR’s Rehabilitation Engineering Research Centers

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a “total approach to rehabilitation”, combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970’s, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program