Possible benefits of Virtual Reality Therapy for stroke

Researchers have been developing a series of virtual reality games and environments to improve mobility after stroke. You could find yourself walking through the looking glass with Alice, or battling against evil rabbits for the carrots in a virtual field. There is a growing collection of research papers showing how virtual reality therapy can help with stroke rehabilitation.

A poster at the American Stroke Association's International Stroke Conference 2010 explained how using the well-known Nintendo Wii™ technology could help stroke survivors to enhance their motor function. The pilot study asked 20 stroke survivors to play a selection of games: one group played cards and Jenga (a balancing game), while the other group played Wii™ tennis and Cooking Mama (which includes cutting and slicing actions). Both groups played eight times over a two-week period, each time for an hour. The researchers concluded:

“Basically, we found that patients in the Wii™ group achieved a better motor function, both fine and gross, manifested by improvement in speed and grip strength,” Saposnik said. “But it is too early to recommend this approach generally. A larger, randomized study is needed and is underway.”⁶

In 2007, a pilot study showed how a low cost virtual reality system could help to improve arm and hand movement after a stroke. The participants wore a headset and glove filled with sensors. They were then immersed in a virtual world where they could move through different environments, such as a house or shop. This allowed them to perform common tasks safely, such as making a cup of tea. After an initial training period they could use the equipment without a therapist, making it possible to practice for much longer periods and increasing their chance of recovery. Researchers wrote:

‘The pilot study has been very successful and we were encouraged to find that even participants with moderate to severe disability following stroke were able to engage positively with the system. We now plan to investigate more prolonged use of virtual reality therapy in a stroke. “It is an exciting project and one that is unique in the UK and Ireland. We are hopeful that this new form of rehabilitation therapy will considerably improve the quality of life for people with stroke.”’⁷

Virtual reality therapy can also be used to improve balance after a stroke. In 2009, a team of researchers divided 24 stroke survivors into two groups. Everyone received the same physiotherapy but one group also received 30 minutes of virtual reality therapy per day. After four weeks, researchers measured both groups and found that participants who had received VRT improved both their balance and their walking significantly more than the other (control) group.⁸

In 2010, a pilot study suggested that a device called HandTutor™ could be used to rehabilitate hand movements. The study was sponsored by Meditouch Ltd, the makers of the HandTutor™ system. The system, which can be used at home, comprises a glove that records finger and wrist motion and MediTutor™ support software. The glove functions like a computer mouse. The patient's task is to move objects on the computer screen. In the study, participants performed a task called 'Track', which involves navigating a ball along a track that moves horizontally on the screen. The software recorded their performance. Information gained from the HandTutor™ system can be used to quantify patient performance, determine therapy goals and monitor patient progress. The study concluded:

'Following 15 consecutive treatment sessions, a significant improvement was observed within the experimental group (95% confidence intervals) compared with the control group.'⁹

Another benefit of virtual reality therapy is that stroke survivors can continue their physical therapy at home. One study showed promising results when researchers sent a series of arm exercises to participants via the Internet. They concluded:

‘These results may favour early discharge from hospital sustained by a telerehabilitation programme…’¹⁰

Arguments against using Virtual Reality Therapy for stroke

There is a lot of excitement about the applications of VRT for stroke. However, some of the clinical trials measured small groups of people, while others studied the participants over a short period of time. For example, one researcher explains that while early signs are promising and “small numbers of patients had shown significant improvement,” they will not know the full picture until they see the results of the ongoing clinical trials.¹¹ This sentiment is repeated in the Journal of Rehabilitation Medicine (2009), which concludes:

‘The studies completed to date support application of virtual reality methods in the treatment of the paretic upper limb after stroke, but the superiority of virtual reality methods in comparison with conventional procedures currently in use is still unproven. Larger samples, adequate controlled study design and follow-up, greater homogeneity in the selection criteria and parameters measuring severity of stroke, motor impairment and recovery are necessary.’¹²

Case histories

1. This video shows a patient using a virtual reality rehabilitation system:
   
   Published with the kind permission of Institute of Neuroinformatics, University of Zurich
2. Stroke Patients Being Helped By Nintendo Wii:
   
   Published with the kind permission of WJAR Digital

Notes and references

1. The researchers explain: ‘Patients often report re-living their original burn experience during wound care; SnowWorld was designed to help put out the fire. Our logic for why VR will reduce pain is as follows. Pain perception has a strong psychological component. The same incoming pain signal can be interpreted as painful or not, depending on what the patient is thinking. Pain requires conscious attention. The essence of VR is the illusion users have of going inside the computer-generated environment. Being drawn into another world drains a lot of attention resources, leaving less attention available to process pain signals. Conscious attention is like a spotlight. Usually it is focused on the pain and woundcare. We are luring that spotlight into the virtual world. Rather than having pain as the focus of their attention, for many patients in VR, the wound care becomes more of an annoyance, distracting them from their primary goal of exploring the virtual world. (‘Virtual Reality Pain Reduction’. On University of Washington Seattle and U.W. Harborview Burn Center website)
2. This video shows how Virtual Reality Therapy helps to overcome a fear of flying and other phobias. ‘Virtual reality therapy helps users’. Reuters Dec 7 2009 1:29PM Aug. 13
3. ‘Hadassah tries to 'trick the brain' with virtual reality to treat physical ailments’ by Judy Siegel-Itzkovich. In The Jerusalem Post; Dec 5, 2008
4. ‘VirHab - A virtual reality system for treatment of chronic pain and disability’ by Feintuch, U., Tuchner, M. et al. In Virtual Rehabilitation International Conference, 2009: June 29 2009-July 2 2009; 83-86
5. This video shows the benefits of VRT for stress, weight loss and other issues. 'Virtual Reality Therapy at Vision Counselling, Perth'. Channel Ten News Story Nov 17 2009.
6. American Heart Association (2010, February 26). ‘Wii video games may help stroke patients improve motor function’. In ScienceDaily.
7. ‘Virtual Reality: Taking Stroke Rehabilitation into the Technological Age’. In University Of Ulster News Release, 27th April 2007
8. ‘Use of virtual reality to enhance balance and ambulation in chronic stroke: a double-blind, randomized controlled study' by Kim JH, Jang SH, et al. In American Journal of Physical Medicine and Rehabilitation. 2009 Sep;88(9):693-701.
9. 'HandTutor™ enhanced hand rehabilitation after stroke - a pilot study' by Carmeli E, Peleg S, Bartur G, Elbo E, Vatine JJ. In Physiotherapy Research International. May, 2010
10. ‘Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach' by Piron L, Turolla A, et al. In Journal of Rehabilitation Medicine. 2009 Nov;41(12):1016-102.
11. ‘Hadassah tries to 'trick the brain' with virtual reality to treat physical ailments’ by Judy Siegel-Itzkovich. In The Jerusalem Post. Dec 5, 2008
12. ‘Virtual reality and motor rehabilitation of the upper limb after generation of progress?’ by Lucca, Lucia Francesca. In Journal of Rehabilitation Medicine. 2009 Nov;41(12):1003-100.