Virtual Reality Technology and Rehabilitation Care

Virtual Reality Technology and Rehabilitation Care
By
Sabrina Small

Virtual reality (VR) technology has been increasingly used in rehabilitation and therapy over the last decade. This paper reviews the literature on the use of VR technology in the context of rehabilitation and therapy, including physical and mental health conditions. The paper discusses the benefits of using VR technology in rehabilitation and therapy, including improved engagement, increased motivation, and reduced anxiety. The paper also examines the potential limitations of VR technology in rehabilitation and therapy, such as cost, accessibility, and limited evidence of long-term effectiveness.

Rehabilitation and therapy have been essential for individuals with physical and mental health conditions to regain function, improve quality of life, and prevent further disability. Traditional rehabilitation and therapy approaches, such as physical therapy, occupational therapy, and cognitive-behavioral therapy, rely on face-to-face interactions between the patient and the therapist.

However, the use of VR technology has been increasingly explored as a complementary or alternative approach to traditional rehabilitation and therapy. VR technology refers to computer-generated three-dimensional environments that simulate real-life situations or experiences. This technology offers a unique opportunity to provide patients with a safe, controlled, and immersive environment for rehabilitation and therapy. There are naturally several obstacles to offering exposure therapy, including patient and therapist concerns, difficulties arranging exposure, and a shortage of mental health providers trained in exposure therapy. VR can help overcome these barriers by providing a controlled and individualized exposure experience.

Virtual Reality exposure therapy, or VRET, has been shown to reduce anxiety and phobia symptoms and is an acceptable and effective alternative to in vivo exposure. It allows the therapist to see what the patient sees in the virtual environment, guiding them through exposure in the office while monitoring and supporting the patient. VRET can also help manage clinic throughput and lower costs associated with intensive anxiety treatment. VRET could also help increase therapist training, improve the efficiency of treatment, and offer patients self-help interventions that may ease suffering and prevent progression to more severe symptoms.

Exposure therapy is a behavioral treatment used to alleviate symptoms of post-traumatic stress disorder (PTSD) by addressing avoidance behavior. This approach involves actively confronting situations, thoughts, and emotions that elicit fear and anxiety to help individuals realize that these experiences are not as dangerous as they seem. However, for some individuals, confronting the feared situation may not be possible or safe, particularly for those with combat-related PTSD. VRET has emerged as a promising treatment option in such cases, where individuals are immersed in a computer-generated virtual environment that closely resembles the feared situation. Studies have shown that VRET may be useful in treating various anxiety disorders, including PTSD among Vietnam and Iraq/Afghanistan war veterans. The use of VRET has the potential to overcome the limitations of traditional exposure therapy and improve the quality of life of individuals with PTSD.

Another way that exposure therapy has been utilized is to help rehabilitate those suffering from addictions. I found a few trials using this approach. One article discusses the effectiveness of virtual exposure therapy (VET) and virtual cognitive behavioral therapy (VCBT) for reducing nicotine addiction in adults. Five VET trials were conducted, with one trial showing effectiveness on craving and cigarette consumption reduction, while two trials found mixed results. One VCBT program involved finding and crushing virtual cigarettes without therapist assistance, and was effective in reducing nicotine addiction and increasing abstinence rates. The other VCBT program involved 10 weekly sessions with personalized exposure to craving and coping skills training, and was effective in reducing cigarette consumption and craving, with better retention rates and self-confidence compared to nicotine replacement therapy alone.

However, the results of this program should be interpreted with caution due to low overall adherence to treatment.

VET has been studied in three controlled trials in Korea for its effectiveness in reducing alcohol craving. The VET approach included relaxation time, craving, and aversive exposure guided by a therapist, and was found to be more effective than a standardized CBT in reducing alcohol craving in 38 abstinent males after 10 biweekly sessions. One trial found VET to be effective in reducing craving in heavy social drinkers after one session compared to light consumers, and was associated with decreased ocular fixation times for alcohol-related markers and improved alcohol-Stroop test scores for both groups. However, evidence for the effectiveness of VET on alcohol dependence reduction has not yet been studied.

Studies on the effectiveness of VET for Gambling Disorder have had mixed results. One study found no reduction in the urge to gamble after a single VET session on 10 lottery players. However, pilot data from another study showed promising results, with a VET protocol being effective in reducing the desire to gamble in frequent players. In a randomized trial, there was no difference in craving reduction between VET and imagined exposure on pathological gamblers who received standardized CBT. Finally, four VET sessions were associated with a stronger sense of control over gambling-related disorders after the third exposure compared to an exposure in imagination in 25 pathological players.

Cognitive rehabilitation is an essential component of therapy for individuals with cognitive impairments caused by various conditions such as traumatic brain injury, stroke, and dementia. Traditional cognitive rehabilitation methods, such as pencil-and-paper exercises, have limitations, such as limited engagement, difficulty in tracking progress, and lack of personalized therapy. VR technology has the potential to enhance cognitive rehabilitation by providing an immersive, personalized, and engaging environment for therapy.

The impact of cognitive impairment on a person’s life is immense, as are the potential benefits of cognitive rehabilitation. Traditional approaches involve therapeutic cognitive interventions to reinforce, strengthen, or establish new patterns of cognitive activity to compensate for neurological damage. However, social events like the COVID-19 pandemic have reduced access to care facilities, and the article proposes telemedicine and VR as potential solutions for cognitive telerehabilitation. Different technologies such as telerehabilitation, VR, and augmented reality all have their advantages and limitations for cognitive telerehabilitation. VR, in particular, has several advantages over traditional rehabilitation, including a high level of ecological validity, increased patient satisfaction and compliance, and the ability to provide immediate feedback.

One study used a VR-based cognitive intervention called “Reh@City”, which aims to address the limitation of paper and pencil tasks in terms of ecological validity. Reh@City is a three-dimensional environment that simulates a city with streets, sidewalks, commercial buildings, parks, and moving cars. The city was designed to have only square or rectangular building blocks and regular street intersections to help patients memorize the number of turns to get to a destination and allow for a more precise control of task difficulty.

Reh@City provides an integrative cognitive training experience where patients are required to accomplish some common ADL’s (activities of daily living) in four frequently visited places: a supermarket, a post office, a bank, and a pharmacy. The places display billboards and products of real spaces and trademarks commonly found in Portugal to help patients relate the VR tasks to the real world. When a task is given, the goal’s optimal path is displayed on a general map highlighted in green, and the Reh@City can be configured to provide a mini-map in the lower half of the screen and/or a guidance arrow to increase or decrease the visuo-spatial orientation demands involved in the navigation task. Patients can press a help button to recall the task instructions and have access again to the task map if needed. Visual feedback elements such as time and point counters are used to give feedback on the accomplishment of task objectives and to reward successful actions. Points are accumulated at each objective completion and at each intermediate task, and points are subtracted whenever a mistake is performed or a help button is used.

What happens when a medical devices company, a university research group, and a stroke unit at a major hospital come together to develop an immersive VR system for stroke rehabilitation? A program called VIRTUE was born. The system uses cost-effective and readily available equipment and has been developed with the input of clinicians and patient representatives, including a stroke patient public involvement group. The scenarios created in VIRTUE were designed by an occupational therapist to follow real-life therapy treatment situations in stroke rehabilitation and to challenge cognitive processes such as attention, planning, sequencing, problem-solving, and memory.

The system uses a modular architecture that allows for personalized therapy and flexibility in practice activities. VIRTUE uses the Oculus Rift S headset and provides a resolution of 2560 by 1440 pixels and a refresh rate of 80 Hz. The scenarios in VIRTUE include a bedroom, bathroom, kitchen, cafe, restaurant, and garden scene, which allow patients to practice activities of daily living in a suitable environment. The system can support models from different manufacturers, and the headset is equipped with two 6 Degree-of-Freedom Touch Controllers that support both orientation and positional tracking, allowing the integration of virtual hands to interact with VR environments.

The VIRTUE program offers a practical exercise for patients to enhance their skills in making toast. The HMD Touch Controller enables them to manipulate objects like knives. Clear audio and written instructions guide the patient, who receives feedback throughout the task. The therapist views the scene through a control panel interface, which displays the patient’s point of view, which is visible on the computer screen. The therapist has the ability to upload patient data, choose a specific scenario, adjust the task’s level of difficulty, and interact with the patient while they are fully immersed in the activity.

However, there are some challenges that are typically associated with using head mounted displays, such as infection control. There were some measures taken to mitigate these risks, such as using disposable masks and alcoholic wipes. Another limitation is the nature of stroke symptoms: tasks should be designed so that they can be completed with either the left or right hand or both, as many stroke patients will be unable to use one side of their body effectively, and implementing these tasks within a serious game allows appropriate feedback to be given to the patient.

The final sector of rehabilitation I will speak about is using VR in motor rehabilitation by creating a safe and ecologically valid environment for patients to engage in challenging behaviors. VR can provide repeated opportunities for tasks that involve multimodal processes and enable improvements in function. Specific postural responses differ in functional contexts compared to paradigms where individual control pathways are manipulated. VR allows for individualized treatment needs while providing increased standardization of assessment and training protocols. The key feature of VR applications is interaction and the broad range of visual interfaces used to create varying degrees of immersion in the VE. The provision of a sense of actual presence in the simulated environment is another cardinal feature of virtual reality.

There are various systems and applications that have been used for balance and posture training, as well as locomotion therapy for patients with Parkinson’s disease. These include a combined HMD display system with a fixed bicycle, flat screen VR systems, and an immersive dynamic virtual environment combined with a posture platform. The use of VR in rehabilitation has shown improvements in balance and functional mobility in community-living individuals with traumatic brain injury and older adults, with participants indicating greater enthusiasm, enjoyment, and improved confidence. For patients with Parkinson’s disease, augmented reality has been used to initiate and sustain walking in akinetic patients, with the effectiveness of the visual cue dependent on the degree and type of akinesia.

Another study aimed to investigate the effects of virtual reality rehabilitation training on balance, gait, and motor function in patients with Parkinson’s disease. The study included 28 patients who were randomly assigned into either the experimental group or the control group. The experimental group received 12 weeks of virtual reality rehabilitation training, while the control group received routine rehabilitation training. The outcomes of the study were assessed using the Berg Balance Scale (BBS), the Timed Up and Go Test (TUGT), the third part of the Unified Parkinson’s Disease Rating Scale test (UPDRS3), and the Functional Gait Assessment (FGA). The results showed that both groups had significant improvements in the BBS, TUGT, and FGA scores after treatment, but there was no significant improvement in the UPDRS3 score in the control group. The scores of the BBS, TUGT, UPDRS3, and FGA in the experimental group were better than those in the control group. The study concluded that virtual reality rehabilitation training can be a beneficial intervention for patients with Parkinson’s disease to improve their balance, gait, and motor function.

In a meta-analysis study that aimed to determine the effectiveness of virtual reality (VR) in rehabilitating the motor function of patients with subacute stroke compared to conventional therapy (CT). The study found that VR interventions resulted in significant improvement in the motor function of affected limbs in patients with subacute stroke compared to pre-intervention values. However, there was considerable heterogeneity, and the observed results were deemed insignificant after a trim-and-fill adjustment of risk of bias, indicating no significant difference between both interventions. The study also reported that the majority of analyzed interventions were designed to improve motor function rather than other outcomes, such as cognitive function or activities of daily living. Additionally, the feasibility of VR-based interventions was assessed in three trials, highlighting the potential benefits of using VR in neurorehabilitation.

In conclusion, virtual reality technology has demonstrated great potential as a complementary or alternative approach to traditional rehabilitation and therapy for various physical and mental health conditions. The benefits of VR technology in rehabilitation and therapy include improved engagement, increased motivation, and reduced anxiety. VR exposure therapy has emerged as a promising treatment option for individuals with PTSD, addiction, and gambling disorder, although more research is needed to evaluate its long-term effectiveness. VR technology also has the potential to enhance cognitive rehabilitation by providing an immersive, personalized, and engaging environment for therapy. However, the limitations of VR technology in rehabilitation and therapy, such as cost, accessibility, and limited evidence of long-term effectiveness, need to be addressed for wider adoption and implementation of VR technology in clinical practice.

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