The future of virtual reality in neurorehabilitation: an expert roundtable
Over the past 15 years, virtual reality (VR) technology has gained ground as a valuable tool in neurorehabilitation.1 In patients with multiple sclerosis (MS), for example, several studies published in 2023 demonstrated improvements in manual dexterity and motor function of the upper limbs, as well as measures of daily functioning, quality of life , mood and treatment satisfaction, following virtual reality training.1-3
Additionally, in a 2022 meta-analysis published in the journal Neurological sciencesresearchers found that home virtual reality training was associated with improvements in postural balance in patients with MS, Parkinson’s disease and stroke.4
In a 2020 multicenter single-blind randomized controlled trial published in Developmental medicine and child neurology, researchers compared the effects of a virtual reality rehabilitation intervention combined with conventional occupational therapy with conventional therapy alone in children with cerebral palsy. The VR group showed greater improvements in upper limb dexterity functions, activities of daily living, and forearm supination.5
According to a 2020 study published in the Journal of Aging and Physical Activity. 6 The intervention was also found to be safe and feasible, although no significant changes in physical or cognitive outcome measures were observed.
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In an ideal world, we would see high-quality clinical trials evaluating virtual reality in all of these patient groups.
To learn more about the state of research and practice of VR technology in neurorehabilitation, we spoke with the following experts:
- Hillel M. Finestone, MDCM, FRCPC, Professor in the Division of Physical Medicine and Rehabilitation at the University of Ottawa and Director of Stroke Rehabilitation Research at Elisabeth Bruyere Hospital in Ontario, Canada
- Lisa Sheehy, PhD, physiotherapist and research associate at the Bruyre Research Institute of the University of Ottawa
- Sean Dukelow, PhD, Professor in the Department of Clinical Neurosciences at the University of Calgary in Alberta, Canada, and Medical Director of Stroke Rehabilitation for the Calgary Stroke Program
In what positive ways has virtual reality transformed the neurorehabilitation space, particularly in terms of patient engagement and treatment engagement?
Dr Finestone: In general, patients appreciate the exercise game activities provided by VR technology. Some of them said it was less boring and time flies faster. Of course the answer depends on the game itself, some are very simplistic and can be seen as boring, but that’s usually not the case.
Dr. Dukelow: I see virtual reality as a tool we can use to gamify the rehab experience, which can help with patient engagement. In a typical rehab setting, virtual reality can be used to enhance things that a clinician might work on with a patient. One of the exciting facets of virtual reality is that it can be used to do things that are unique and hard to do in a standard rehab setting or in an all-natural environment. An example might be trying to train a patient to search for objects in an area where they have lost their visual fields or have attentional impairment, this is something that can be accomplished quite easily in VR.
Many patients really enjoy virtual reality because of the game-based approach. It has a bit of an addictive side to it considering how many people enjoyed playing games like Tetris and Candy Crush in the past. Granted, we now have a whole generation of people who grew up with video games in the healthcare system, so the idea of doing part of rehabilitation by playing a VR game isn’t so foreign.
What are the differences and potential barriers to getting adults and children to use virtual reality as part of rehabilitation therapy?
Dr. Dukelow: I think one of the barriers to VR engagement has been the use of headsets among older people, which could cause nausea issues. Traditionally, this has been handled by VR systems that are slightly less immersive than large screens, but newer headsets have higher refresh rates, so we’re seeing fewer of these issues.
Can you discuss the neurobiological mechanism that makes virtual reality successful in neurorehabilitation?
Dr Sheehy: The use of virtual reality follows many principles of motor learning, namely repetition, task-specific practice, meaningful practice, augmented feedback, observational learning, and motivation. Some studies show increased neural activity in the affected brain due to participation in VR therapy.7
What makes the use of virtual reality in neurorehabilitation such an intriguing option for clinicians?
Dr Sheehy: Virtual reality can be implemented by therapists, rehabilitation assistants, family members or volunteers. It can be used as a therapeutic modality or as an adjunct therapy, or to provide additional rehabilitation exercises. It can be used for inpatients, outpatients, in the community and at home. It can be used for people with subacute and chronic diseases.
Dr. Dukelow: As I mentioned, virtual reality is an intriguing option for clinicians because it can augment what they do in their individual or group therapy sessions in the real world, and it can go beyond what the clinician is able to do in the real world. world. I’m not sure there is a well-established mechanistic explanation for why VR can outperform other therapies. Some have suggested it has to do with increased engagement. We know that if a patient is more engaged and motivated, they are more likely to exercise.
In neurorehabilitation, what you do matters, but most clinicians would say what you do matters too.
Can you describe the evolution of virtual reality-based interventions for physical and cognitive rehabilitation of various neurological conditions?
Dr. Dukelow: In general, when a technology initially enters neurorehabilitation, it is often tested by an individual or a group of people who have access to a certain patient population and believe that they could benefit from this technology. Over time, as the technology becomes more widely available, more people see it and think about its potential applications for other populations. You see creep or spread in the indication.
This has happened for many different interventions in the field of neurorehabilitation, from electrical stimulation to robotics to non-invasive brain stimulation. When a technology is non-invasive like virtual reality, it is very easy for clinicians to try it out for different conditions. I think it’s important to say here that at some point new technology needs to be properly tested in well-conducted clinical trials to see if it actually improves these conditions.
What conversations have you had with patients newly exposed to VR technology?
Dr Sheehy: Most patients appreciate virtual reality, and it motivates them to do more therapy. This also applies to older patients, even in their 90s, or who have no previous experience with virtual reality or with computers. Some who are very tech-savvy or overwhelmed by their new reality are not interested. Those with a lot of gaming experience tended to find it lackluster and rather lackluster.
Patients prefer the most intuitive and gamified games, i.e. the scoring system reflects success and some participants in our research had the most difficulty with games incorporating complex visuospatial tracking.6
Dr. Dukelow: Honestly, these are usually pretty short conversations. Of course, we need to review the potential risks and benefits of any treatment, but generally people are willing to try it because the risks are minimal. Do we have people who are not interested? Sure, we have the occasional person who isn’t at all interested in video games or trying something tech-related, but most people want to try.
Which patient population do you think will benefit the most from virtual reality and which population do you think should be the primary focus of research in this area?
Dr Finestone: I believe that virtual reality assisted neurorehabilitation is a useful complement to traditional rehabilitation methods. I don’t think it can completely replace physiotherapists and occupational therapists. I think most neurorehabilitation patients would benefit from this technology. My vision for the future is that there will be specific games that target specific neurological losses and disabilities.
For example, a patient who has loss of balance due to cerebellar infarction will be challenged with VR games targeting walking, sitting and standing balance, and other similar activities. A patient with hemiparesis will play games targeting the weakened right arm and leg. There are currently specific exercise programs, especially with physiotherapy, which are based on virtual reality.
Dr. Dukelow: Virtual reality is a tool, and rehab tools have the ability to cross different patient populations. With this lens, I think we see there are potential benefits for cognition, gait and balance, and I think there is tremendous potential for motor recovery. You will notice that these areas cross patient populations.
Would I like to see more effort and funding dedicated to stroke? Selfishly, as a stroke specialist, I would say yes, but I think there’s great potential in the other patient groups you’ve mentioned, and those patients also have huge needs for better interventions. In an ideal world, we would see high-quality clinical trials evaluating virtual reality in all of these patient groups.
Note to editors: This interview has been edited for clarity and length.
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