VR-based rehabilitation of cognitive functions among stroke-survivors

You do realize that if you want to motivate survivors to do their rehab you give  them EXACT REHAB PROTOCOLS LEADING TO 100% RECOVERY?  That alone is enough motivation to get them going. Guidelines are useless for that motivation.

 VR-based rehabilitation of cognitive functions among stroke-survivors

Severin A. Eliassen1, Harald Soleim1, Atle B. Geitung1 and Lars Peder V. Bovim2,3
1Faculty of Engineering, Western Norway University of Applied Sciences
2SimArena Rehabilitation Lab, Department of Health and Functioning, Western Norway University of Applied Sciences,
Bergen, Norway
3The Vitality Centre for Children and Youth, Haukeland University Hospital, Bergen, Norway

Abstract

Stroke is one of the most common causes of long-term disability, with the risk of decreased cognitive
functioning, resulting in a significant need for rehabilitation modalities. For modalities to be effective,
there is an increasing focus on making them motivating and individualized. This study implements and tests two immersive Virtual Reality (VR) based games aimed at cognitive rehabilitation. The Box Painting Game and The Plane Game were developed in iterations with health professionals. The games are customizable for the therapist by using a computer or a tablet application. The usability and usefulness of the proposed solution were evaluated via the system usability scale (SUS) and semi-structured interviews in two iterations. These included four health professionals. Evaluations show that the games’ usability is acceptable and has the potential to increase the engagement and motivation of stroke survivors.
Keywords
Virtual reality, Cognitive functions, Stroke, Rehabilitation, Interventions, Serious games.
1. Introduction
In 2019, stroke was the second most common cause of death and the third most common cause of disability-adjusted life years globally [ 1 , 2 ] and in Norway [2 ]. As healthcare is constantly evolving and new studies have been conducted, death rates have decreased [ 3 ]. This leads to an increasing number of patients who need extensive rehabilitation. The goal of rehabilitation is to give the affected as much independence as possible(WRONG!  The goal is 100% recovery!) and be able to go back to work and enjoy the hobbies they love.Keeping the motivation of the patient high is one of today’s problems during traditional rehabilitation, as the patients can often perceive the exercises as monotone and repetitive [ 4]. Another challenge with stroke is the significant difference in impairments for each patient [ 5, 6]. The project aims to tackle these problems by developing two fully immersive VR games with adjustable difficulty to supplement traditional rehabilitation. However, the work presented is limited to evaluations with physical therapists at this stage. This limitation is to first see the acceptability and usability of the games as a supplement. The therapists are a good starting point in assessing the usefulness. They are also the entry point of taking the games into the rehabilitation process and recruiting patients to a clinical trial. Then, after achieving a satisfying result, patients can be involved to check the motivational and engagement gains and the effectiveness of the proposed games. In a related project by Førde hospital trust [ 7 ], Beat Saber 1 is being used to supplement the rehabilitation of sitting and standing balance among stroke survivors. They observe with Beat Saber that patients have increased motivation and engagement in the treatment, in accordance with [ 9 ]. Technology-assisted rehabilitation is not a new concept but rather an emerging field. Tobler-Ammann et al. [ 10 ] designed nine exergames for rehabilitation of visuospatial neglect after stroke. The games were Virtual Reality (VR) experiences developed for use on a computer monitor and with the Novint Falcon haptic controller. This is a 3D touch controller with force feedback [ 11 ]. They used the technology acceptance model, group interviews with the therapists, and individual interviews with the patients to evaluate the games. The study found that the therapist was more skeptical about using these games than the patients. Patients perceived the games as a motivating and nice change from regular rehabilitation. However, they could become repetitive, and some had trouble seeing their relevance to real life at first or at all. Both groups of users were not convinced to use exergames after the trial period, as the patients preferred to use their time on other activities after being discharged. Faria et al. [ 12] compare traditional paper-pencil cognitive training methods with adaptive training in VR. The article uses Reh@City v2.0 [ 13], a VR game that simulates eight daily life activities. The game is experienced through a computer monitor, where interactions happen through a motion-tracking camera. These activities are spread across eight different locations in a city, including a bank, a store, and a post office. For the evaluation, they recruited 35 outpatients who had an ischemic stroke 2 at least six months prior to the study (18 in the pen-paper group and 17 in VR). Their findings do not show a significant performance difference between the paper-pencil intervention and VR, but VR users experienced more intensive training, leading to more repetitions and challenging tasks. The authors concluded that it could lead to more cognitive improvements, but further research with a larger sample size and other rehabilitation tasks is necessary. Gamito et al. [ 15 ] designed a Virtual Reality cognitive training application. The VR application included a scenario that consisted of several daily life activities for training cognitive functions such as working memory, visuospatial orientation, selective attention, recognition memory, and digit retention. They recruited 20 stroke patients, where 10 used the VR application and 10 were in the control group. Overall their results indicate benefits in memory and attention but no significant results in visual memory. The presented articles are not an exhaustive list of related works. There exists a wide range of projects and studies on rehabilitation using VR, both fully immersive and not, such as [9, 16, 17, 18, 19, 20, 21]. As is evident from the presented related work, gamification of the rehabilitation process is not a new trade, and quite a bit of novel work is done, both in terms of cognitive and physical rehabilitation of stroke survivors. However, the use of fully immersive VR for cognitive stroke rehabilitation is rather understudied, as a lot of the related work is done through screen-based VR [ 10 ], [ 12 ], [ 17 ], and some require specialized tools and controllers [10 ], [ 12 ]. In addition, there is work that uses keyboard and mouse interaction instead of fully utilizing the potential of head-mounted displays (HMD) [20].