Using mixed methods to evaluate efficacy and user expectations of a virtual reality-based training system for upper-limb recovery in patients after stroke: a study protocol for a randomised controlled trial.

BACKGROUND: In recent years, virtual reality has been introduced to neurorehabilitation, in particular with the intention of improving upper-limb training options and facilitating motor function recovery. METHODS/DESIGN: The proposed study incorporates a quantitative part and a qualitative part, termed a mixed-methods approach: (1) a quantitative investigation of the efficacy of virtual reality training compared to conventional therapy in upper-limb motor function are investigated, (2a) a qualitative investigation of patients' experiences and expectations of virtual reality training and (2b) a qualitative investigation of therapists' experiences using the virtual reality training system in the therapy setting. At three participating clinics, 60 patients at least 6 months after stroke onset will be randomly allocated to an experimental virtual reality group (EG) or to a control group that will receive conventional physiotherapy or occupational therapy (16 sessions, 45 minutes each, over the course of 4 weeks). Using custom data gloves, patients' finger and arm movements will be displayed in real time on a monitor, and they will move and manipulate objects in various virtual environments. A blinded assessor will test patients' motor and cognitive performance twice before, once during, and twice after the 4-week intervention. The primary outcome measure is the Box and Block Test. Secondary outcome measures are the Chedoke-McMaster Stroke Assessments (hand, arm and shoulder pain subscales), the Chedoke-McMaster Arm and Hand Activity Inventory, the Line Bisection Test, the Stroke Impact Scale, the MiniMentalState Examination and the Extended Barthel Index. Semistructured face-to-face interviews will be conducted with patients in the EG after intervention finalization with a focus on the patients' expectations and experiences regarding the virtual reality training. Therapists' perspectives on virtual reality training will be reviewed in three focus groups comprising four to six occupational therapists and physiotherapists. DISCUSSION: The interviews will help to gain a deeper understanding of the phenomena under investigation to provide sound recommendations for the implementation of the virtual reality training system for routine use in neurorehabilitation complementing the quantitative clinical assessments. TRIAL REGISTRATION: Cliniclatrials.gov Identifier: NCT01774669 (15 January 2013).

Enhancement of motor imagery-related cortical activation during first-person observation measured by functional near-infrared spectroscopy.

It is known that activity in secondary motor areas during observation of human limbs performing actions is affected by the observer's viewpoint, with first-person views generally leading to stronger activation. However, previous neuroimaging studies have displayed limbs in front of the observer, providing an offset view of the limbs without a truly first-person viewpoint. It is unknown to what extent these pseudo-first-person viewpoints have affected the results published to date. In this experiment, we used a horizontal two-dimensional mirrored display that places virtual limbs at the correct egocentric position relative to the observer. We compared subjects using the mirrored and conventional displays while recording over the premotor cortex with functional near-infrared spectroscopy. Subjects watched a first-person view of virtual arms grasping incoming balls on-screen; they were instructed to either imagine the virtual arm as their own [motor imagery during observation (MIO)] or to execute the movements [motor execution (ME)]. With repeated-measures anova, the hemoglobin difference as a direct index of cortical oxygenation revealed significant main effects of the factors hemisphere (P = 0.005) and condition (P ≤ 0.001) with significant post hoc differences between MIO-mirror and MIO-conventional (P = 0.024). These results suggest that the horizontal mirrored display provides a more accurate first-person view, enhancing subjects' ability to perform motor imagery during observation. Our results may have implications for future experimental designs involving motor imagery, and may also have applications in video gaming and virtual reality therapy, such as for patients following stroke.

Trial-to-trial variability differentiates motor imagery during observation between low versus high responders: a functional near-infrared spectroscopy study.

Trial-to-trial variability is a well-known issue in brain signals measured using functional near-infrared spectroscopy (fNIRS). We aimed to investigate whether trial-to-trial variability does provide information about individual performance. Seventeen subjects observed a virtual reality grasping task in first-person view while either imagining (motor imagery during observation, MIO) or imitating (motor execution, ME) the movements. Each condition was performed with the display in one of two positions, a conventional vertical position and a mirrored horizontal position which placed the virtual arm in the correct position relative to the viewpoint. Averaged oxy-hemoglobin concentration Δ[O(2)Hb] showed that the responses could be differentiated into two distinct groups: low responders (LR) and high responders (HR). Within groups, two main sources of trial-to-trial variability were identified: (a) the Δ[O(2)Hb] amplitude, with largest amplitudes in ME conditions (group HR) and smallest amplitudes in MIO conditions (group LR), and (b) the sign of Δ[O(2)Hb], with positive responses occurring most frequently during ME (group HR) and negative responses most frequently during MIO (group LR). Furthermore, the trial-to-trial dynamics differed between groups and could be described in group LR as inverted polynomial U-shaped curve in the mirror conditions (ME-mirror, MIO-mirror). Last, trial-to-trial variability was significantly dependent on task modality, i.e. ME (group HR) versus MIO (group LR), and/or the mirrored display positions (group LR). Our results show a relationship of trial-to-trial variability to individual MI performance, which may be of significance for neurorehabilitation applications. Although the sources of trial-to-trial variability remain unknown, we suggest that they may contribute to future neurofeedback applications.