Fun and Games: Virtual Reality Turns the Work of Rehab into Play

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By Miki Fairley

Imagine a world in which physical and occupational therapy are so enjoyable that sometimes patients don't want to stop!

Researchers from several countries are exploring an exciting new avenue for rehabilitating persons suffering from such conditions as stroke, cerebral palsy, spinal cord injury, and muscular dystrophy-using the virtual reality (VR) world of video games. The current and potential benefits are considerable: increased patient compliance with correspondingly better outcomes, not to mention more cost-effective treatment. Patients have achieved increased speed and coordination in movement, greater independence in activities of daily living (ADL), and even stronger bones and muscles.

The term "virtual reality" or "virtual environment" encompasses a variety of definitions. One widely used definition is, "A high-end user-computer interface that involves real-time simulation and interaction through multiple sensorial channels [vision, sound, touch, smell, taste]" (Virtual Reality, Second Edition, 2003, Grigore C. Burdea, Philippe Coiffet).

Video game-based technologies can help patients with neurological impairments to gain functional abilities in two ways: (1) by taking advantage of the brain's plasticity to help rewire impaired circuits; and (2) by enabling muscle and bone to regain strength simply through increased use, depending on the type and duration of therapy.

Neuroplasticity, also called brain plasticity, cortical plasticity, or cortical remapping, describes the brain's marvelous capacity to reorganize itself by forming new neural connections throughout life. "Neuroplasticity allows the neurons in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment," according to MedicineNet.com. "Brain reorganization takes place by mechanisms such as 'axonal sprouting' in which undamaged axons grow new nerve endings to reconnect neurons whose links were injured or severed." New neural pathways are formed to accomplish needed functions. For instance, if one hemisphere of the brain is damaged, the other hemisphere may take over some of its functions by reorganizing and forming new connections between intact neurons. "In order to reconnect, the neurons need to be stimulated through activity," notes MedicineNet-and this is where therapy steps in.

These technologies also incorporate haptics and constraint-induced movement therapy (CIMT) principles. "Haptics" refers to the sense of touch. In computer technology, it applies to a device that allows a user to interact with a computer by receiving tactile feedback; for example, glove or pen devices that allow users to touch and manipulate three-dimensional virtual objects. CIMT forces the use of the affected side by restraining the unaffected side; in these technologies, the affected side is used to operate the video games.

Exploring New Technologies

A Rutgers University engineering student (left) helps a young cerebral palsy patient as he plays a virtual reality video game to improve his hand function. The teen is able to play this fun, therapeutic game in his own home, without having to travel to a clinic. Photograph courtesy of Meredith Golomb, MD, Riley Hospital, Indianapolis, Indiana.

In looking at some of these new technologies, it's important to note that these are not apples-to-apples comparisons. Most are currently in the pilot-study stage, and only a few currently have larger studies planned. The different technologies are applied to different patient populations varying in age, type and level of impairment, and other factors. However, they offer an exciting glimpse into a frontier of future possibilities. In fact, the first one we will look at is ready now for clinical application because it requires no special modification.

'Wii' Can Do It

Wii™ VR game technology may help persons recovering from cerebrovascular accidents (CVA) to regain both gross and fine motor movements, according to research presented at the American Stroke Association International Conference 2010, held February 23-26 in San Antonio, Texas. Wii technology uses wireless controllers that interact with players in real time. A motion-detector system enables players to see their actions on a television screen with nearly real-time sensory feedback.

The pilot study included 22 stroke survivors, with 11 randomized to the Wii system and the others to standard recreational therapy using cards or Jenga®, a block-balancing and stacking game. Patients had suffered mild to moderate ischemic or hemorrhagic stroke and had an initial arm-deficit score of 4 or higher on the Chedoke-McMaster Scale. The Wii group outperformed the other group, achieving better fine and gross motor function, shown by improvement in speed and grip strength, according to lead investigator Gustavo Saposnik, MD, MSc, director of the Stroke Outcomes Research Unit at the Li Ka Shing Institute, St. Michael's Hospital, Toronto, Ontario, Canada.

Bayley

"The beauty of virtual reality is that it applies the concept of repetitive tasks, high-intensity tasks, and task-specific activities, that activates special neurons [referring to the mirror neuron system, according to the article] involved in mechanisms of cortical reorganization,'' Saposnik said, as quoted in ScienceDaily, February 26. "Effective rehabilitation calls for applying these principles." A mirror neuron is a neuron that fires both when someone acts and when someone observes the same action performed by another.

And the beauty of Wii is that in this study and in another application, the technology did not need any modification; it could be used "right out of the box."

The study used Wii Tennis and Wii Cooking Mama. "We chose these particular programs because they are applicable to daily life," says Mark Bayley, MD, FRCPC, medical director of the Neuro Rehabilitation Program at Toronto Rehabilitation Institute's Neuro Rehabilitation Center and co-chair of the Canadian Stroke Strategy Best Practices, based in Ottawa, Ontario. The movements required in these games are similar to many of the movements needed for ADL, he explains. "We chose applications to help take people to a higher level of independence and self-care," he says, adding that a larger multicenter study is planned. Commenting on the high hourly cost of therapist treatment, Bayley says, "If we could use Wii for an hour [replacing some part of the therapist's time] and get the same results, it would be very cost-effective." Wii games could also be incorporated into at-home therapy. Current standard rehabilitation approaches can be time- and therapy-intensive, not always available, and usually have poor compliance, according to Saposnik, as quoted by Pauline Anderson in Medscape Medical News on March 26. However, the Nintendo system is more attractive and accessible to patients; they become more engaged because it's fun, Saposnik says.

Wii's for Warriors

Wii's technology can help not only persons with neural impairments, but also amputees, according to a news story on WTOP Radio (www.wtop.com), Washington DC, March 26.

After suffering landmine blast injuries in Afghanistan, Air Force Staff Sgt. David Flowers was having a difficult time in therapy with his prosthetic leg until his therapist at Walter Reed Army Medical Center (WRAMC), Washington DC, suggested he try the Wii Fit. "Within about nine days of just playing that thing every single day, not even very long, just a couple hours a day, I was able to start walking with a walker, and then a few days later just two canes," Flowers says.

Flowers and his wife founded "Wii's for Warriors," a group that gives free Wii Fit games to amputees at WRAMC. Army Staff Sgt. James Clark, 25, received a Wii through the program. Clark lost his left leg due to a bomb explosion in Afghanistan, and his right leg was badly damaged. He's now using the Wii's slalom skiing game as part of his rehabilitation, according to WTOP. "It trains you to get up on your toes and back on your heels," Clark says.

Army 1st Lt. Dan Berschinski, 25, also was injured in Afghanistan. He lost his right leg from the hip down, and his left was amputated above the knee. Seven months later, Berschinski is walking on prostheses and using the Wii to regain balance and strength, according to WTOP. "The therapists are pleasantly surprised. They say I'm moving along much faster than they thought I would," Berschinski says.

One caveat: Wii use, when unsupervised by healthcare professionals, could result in "Wiitis," a type of tendonitis caused by overuse or increased blood pressure and pulse due to energetic interactions ("Acute Wiitis," Bonis J, The New England Journal of Medicine, 2007, 356(23):2431-32).

Video Gaming Increases CP Kids' Compliance

Virtual reality therapies can open the door to more use of telerehabilitation, in which patients do therapy at home and are remotely monitored by healthcare professionals via the Internet. Telerehabilitation thus reduces the number of clinic visits, freeing patients from some travel time, cost, and disruption of family schedules.

Teenage participants with severe hemiplegic cerebral palsy who participated in a pilot study of remotely monitored video-game therapy showed improved hand function and forearm-bone health. The young people not only had fun, the therapy also improved their ability to perform two-handed activities of daily living, such as dressing, eating, cooking, and other tasks.

A collaboration between the Indiana University School of Medicine and the Rutgers University Tele-Rehabilitation Institute, the pilot study involved installing VR video games in the homes of three participants. Participants were asked to exercise the plegic hand 30 minutes a day five days a week for six to ten months. During therapy, they wore a Fifth Dimension Technologies Ultra sensing glove and played custom-developed Java 3D games on a modified PlayStation® 3 (PS3). The sensor glove was attached to the remotely monitored video-game console, which was networked to the collaborating institutions.

"Teenagers are not a very compliant population," observes Grigore (Greg) Burdea, PhD, professor of electrical and computer engineering at Rutgers University, Camden, New Jersey, and director of the Tele-Rehabilitation Institute (www.ti.rutgers.edu/ps3hemi.php), "so we decided on a technology that would attract them."

"I wanted a type of therapy that the child would really want to do," says Meredith R. Golomb, MD, MSc, associate professor of neurology at Indiana University School of Medicine and pediatric neurologist at Riley Hospital for Children, Indianapolis, Indiana, "What I've seen over and over again in clinic is that these kids would go through so much therapy and get burned out on it because it's hard to keep moving that limb. They would make improvement and then backslide."

The child's disability and therapy requirements also can strain family relationships. "What often happens in families is that one parent would get really involved in the therapy to help the child improve, and the other parent would be more laid back, saying, 'Oh, let him alone. He doesn't have to do it if he doesn't want to.' The parent pushing the therapy would feel bad because the child was always angry at them." Golomb wanted to find a therapy that would not result in a battle between parent and child, a type of therapy in which the teen might say, "Hey, Mom, can I do a half hour of therapy before I go to bed?"

"Families sometimes break apart when there is a child with disabilities," Golomb says. "They may be fighting about how much time and resources their family should put into the therapy. There is a need for therapies that are not expensive and that are actually fun to do and not a source of conflict."

Although the technology is highly important, it's only part of the story, according to Burdea. "The technology doesn't take away the human element. If there are problems between the parents or within the family, that will be reflected on the child's peace of mind and focus on the therapy. Having someone to pay attention and encourage him is so important."

Research has shown that a relaxed mental state aids rehabilitation, Burdea points out. "If the patient is relaxed, has peace of mind, and can concentrate, he will show greater improvement."

Golomb believes the video-game technology has potential to help patients with other neurological and orthopedic conditions such as stroke, muscular dystrophy, and multiple sclerosis. "We hope to obtain funding to test other conditions," she says.

"Both Greg [Burdea] and I feel that computer-aided telerehabilitation is the future of rehab," Golomb adds. "It eventually can bring increased intensity of rehabilitation to patients for low cost [with further development], although it is expensive now. It can bring rehab to those who would have difficulty accessing it otherwise, to everyone from the poorest of the poor in small villages to the well-to-do with busy schedules or heavy family obligations."

Golomb and Burdea along with colleagues have authored two papers on their study: "In-home Virtual Reality Videogame Telerehabilitation in Adolescents with Hemiplegic Cerebral Palsy," in the January 2010 issue of the Archives of Physical Medicine & Rehabilitation, and "Feasibility of Modified Remotely Monitored In-Home Gaming Technology for Improving Hand Function in Adolescents With Cerebral Palsy," in IEEE Transactions on Information Technology in Biomedicine, March 2010.

In the IEEE paper, Burdea and colleagues look to future investigation needs, which include the following:

  1. "Finding a glove more suitable to the abnormal hand configuration of clients with cerebral palsy. Such a glove needs to be easier to put on and take off and be more rugged than the 5DT glove used in the present study.
  2. "Developing new rehabilitation games, including games to train finger fractionation (independent finger movement), endurance, power output (the ability to exert mechanical work over time), and force exertion. With more game choice, the clients will also have more freedom as far as what they choose to play, and a broader range of training methods will be explored.
  3. "Finding a more open computing configuration than the PS3. Either Sony Co., the game console manufacturer, will allow access to the graphics hardware or platforms that provide sufficient RAM and easy system programming will be investigated."

A new scientific society, the International Society for Virtual Rehabilitation (www.isvr.org) has been formed, Burdea says, adding, "This society is striving to represent this new field of science and to encourage its growth."

Texas Researchers Achieve Three Goals in One

O'Malley

Engineers from Rice University, Houston, Texas, teamed with doctors and researchers from TIRR/Memorial Hermann Hospital, Houston, and the University of Texas-Houston Medical School to develop a computer-based system for physical rehabilitation. The research accomplished three goals, according to system architect Marcia K. O'Malley, PhD, assistant professor, mechanical engineering and materials science at Rice University and director of Rice's Mechatronics and Haptic Interfaces (MAHI) Laboratory. The therapy improved the test subjects' range of motion (ROM) and general functional ability, helped develop better assessment measures that can be correlated with clinical assessment measures, and helped develop software that is more adaptive to the needs of an individual patient.

Exoskeleton rehabilitation robot donned by participant. Photograph courtesy of Marcia O'Malley, PhD, Rice University.

CIMT has shown beneficial results; however, it is highly time intensive and requires a detailed prescribed protocol, O'Malley explains. "One reason CIMT hasn't been widely adopted is because it requires so much in terms of therapist personnel resources. We decided to try a protocol of 60 percent time in conventional therapy and 40 percent with robotics to see if we could achieve the same outcomes as with conventional therapy alone." The Rice team designed a robotic interface similar to a video game. "It's a fairly high-end robotic device with motors and sensors with a handle and joystick that can be pushed and pulled and which guides movements by offering resistance to wrong movements as the user moves objects on the screen," O'Malley explains.

The robotic joystick also obtained data to be used in assessment measures. "There are reasons why we would want to use robotic data as well as clinical measures: (1) we can do an assessment more frequently-every time the patient comes in; and (2) with clinical scales, therapists might anecdotally observe improvement or the patient might report improvement; however, robotic measures are more sensitive to small fluctuations in capability; and (3) we can use this data to help develop the software to automatically adjust to the patient's capabilities on any given day. As the patient continues to improve, we can enable the software to automatically provide the appropriate amount of resistance based on their score. As the software is currently set up, the therapist makes observations and decides what difficulty level to set on the software."

The research team is moving to the next level, using a robotic exoskeleton device built in the Rice lab. The device can provide therapy and collect data relative to elbow flexion/extension, forearm pronation/supination, wrist flexion/extension, and radial/ulnar deviation.

A participant seated at a rehabilitation interface with a joystick-based robot and graphical display of the task. Photograph courtesy of Marcia O'Malley, PhD, Rice University.

"Another direction we're going is seeing if we can get the same robotic rehabilitation benefits for spinal cord injury that we have in stroke," O'Malley says. "We're in the very early stages right now. We will be using the same exoskeleton device and are currently developing the software and modifying the hardware." The joystick and exoskeleton therapy modalities could have application to other conditions such as cerebral palsy and muscular dystrophy, O'Malley adds.

O'Malley and colleagues published a paper on the study, "Comparison of Robotic and Clinical Motor Function Improvement Measures for Sub-Acute Stroke Patients," at the 2008 IEEE International Conference on Robotics and Automation and a paper, "Normalized Movement Quality Measures for Therapeutic Robots Strongly Correlate with Motor Impairment Measures," IEEE Transactions on Neural Systems and Rehabilitation Engineering, April 2010.

Research Presses On

This is only a sample of the virtual reality therapy research under way. Research is progressing in the United Kingdom and Israel as well. VR technology can expand the array of clinical solutions for neural impairments to complement conventional therapy, orthotic care, and other treatment options. Although most of these technologies are not yet clinically available, video games are paving the way for therapy that not only works but is challenging and fun to do.

Miki Fairley is a freelance writer based in southwest Colorado. She can be reached at