Home-Based Virtual Reality-Augmented Training Improves Lower Limb Muscle Strength, Balance, and Functional Mobility following Chronic Incomplete Spinal Cord Injury.

Key factors positively influencing rehabilitation and functional recovery after spinal cord injury (SCI) include training variety, intensive movement repetition, and motivating training tasks. Systems supporting these aspects may provide profound gains in rehabilitation, independent of the subject's treatment location. In the present study, we test the hypotheses that virtual reality (VR)-augmented training at home (i.e., unsupervised) is feasible with subjects with an incomplete SCI (iSCI) and that it improves motor functions such as lower limb muscle strength, balance, and functional mobility. In the study, 12 chronic iSCI subjects used a home-based, mobile version of a lower limb VR training system. The system included motivating training scenarios and combined action observation and execution. Virtual representations of the legs and feet were controlled via movement sensors. The subjects performed home-based training over 4 weeks, with 16-20 sessions of 30-45 min each. The outcome measures assessed were the Lower Extremity Motor Score (LEMS), Berg Balance Scale (BBS), Timed Up and Go (TUG), Spinal Cord Independence Measure mobility, Walking Index for Spinal Cord Injury II, and 10 m and 6 min walking tests. Two pre-treatment assessment time points were chosen for outcome stability: 4 weeks before treatment and immediately before treatment. At post-assessment (i.e., immediately after treatment), high motivation and positive changes were reported by the subjects (adapted Patients' Global Impression of Change). Significant improvements were shown in lower limb muscle strength (LEMS, P = 0.008), balance (BBS, P = 0.008), and functional mobility (TUG, P = 0.007). At follow-up assessment (i.e., 2-3 months after treatment), functional mobility (TUG) remained significantly improved (P = 0.005) in contrast to the other outcome measures. In summary, unsupervised exercises at home with the VR training system led to beneficial functional training effects in subjects with chronic iSCI, suggesting that it may be useful as a neurorehabilitation tool. TRIAL REGISTRATION: Canton of Zurich ethics committee (EK-24/2009, PB_2016-00545), ClinicalTrials.gov: NCT02149186. Registered 24 April 2014.

Intensive virtual reality-based training for upper limb motor function in chronic stroke: a feasibility study using a single case experimental design and fMRI.

PURPOSE: To evaluate feasibility and neurophysiological changes after virtual reality (VR)-based training of upper limb (UL) movements. METHOD: Single-case A-B-A-design with two male stroke patients (P1:67 y and 50 y, 3.5 and 3 y after onset) with UL motor impairments, 45-min therapy sessions 5×/week over 4 weeks. Patients facing screen, used bimanual data gloves to control virtual arms. Three applications trained bimanual reaching, grasping, hand opening. Assessments during 2-week baseline, weekly during intervention, at 3-month follow-up (FU): Goal Attainment Scale (GAS), Chedoke Arm and Hand Activity Inventory (CAHAI), Chedoke-McMaster Stroke Assessment (CMSA), Extended Barthel Index (EBI), Motor Activity Log (MAL). Functional magnetic resonance imaging scans (FMRI) before, immediately after treatment and at FU. RESULTS: P1 executed 5478 grasps (paretic arm). Improvements in CAHAI (+4) were maintained at FU. GAS changed to +1 post-test and +2 at FU. P2 executed 9835 grasps (paretic arm). CAHAI improvements (+13) were maintained at FU. GAS scores changed to -1 post-test and +1 at FU. MAL scores changed from 3.7 at pre-test to 5.5 post-test and 3.3 at FU. CONCLUSION: The VR-based intervention was feasible, safe, and intense. Adjustable application settings maintained training challenge and patient motivation. ADL-relevant UL functional improvements persisted at FU and were related to changed cortical activation patterns. Implications for Rehabilitation YouGrabber trains uni- and bimanual upper motor function. Its application is feasible, safe, and intense. The control of the virtual arms can be done in three main ways: (a) normal (b) virtual mirror therapy, or (c) virtual following. The mirroring feature provides an illusion of affected limb movements during the period when the affected upper limb (UL) is resting. The YouGrabber training led to ADL-relevant UL functional improvements that were still assessable 12 weeks after intervention finalization and were related to changed cortical activation patterns.

Virtual reality-augmented neurorehabilitation improves motor function and reduces neuropathic pain in patients with incomplete spinal cord injury.

BACKGROUND: Neurorehabilitation interventions to improve lower limb function and neuropathic pain have had limited success in people with chronic, incomplete spinal cord injury (iSCI). OBJECTIVE: We hypothesized that intense virtual reality (VR)-augmented training of observed and executed leg movements would improve limb function and neuropathic pain. METHODS: Patients used a VR system with a first-person view of virtual lower limbs, controlled via movement sensors fitted to the patient's own shoes. Four tasks were used to deliver intensive training of individual muscles (tibialis anterior, quadriceps, leg ad-/abductors). The tasks engaged motivation through feedback of task success. Fourteen chronic iSCI patients were treated over 4 weeks in 16 to 20 sessions of 45 minutes. Outcome measures were 10 Meter Walking Test, Berg Balance Scale, Lower Extremity Motor Score, Spinal Cord Independence Measure, Locomotion and Neuropathic Pain Scale (NPS), obtained at the start and at 4 to 6 weeks before intervention. RESULTS: In addition to positive changes reported by the patients (Patients' Global Impression of Change), measures of walking capacity, balance, and strength revealed improvements in lower limb function. Intensity and unpleasantness of neuropathic pain in half of the affected participants were reduced on the NPS test. Overall findings remained stable 12 to 16 weeks after termination of the training. CONCLUSIONS: In a pretest/posttest, uncontrolled design, VR-augmented training was associated with improvements in motor function and neuropathic pain in persons with chronic iSCI, several of which reached the level of a minimal clinically important change. A controlled trial is needed to compare this intervention to active training alone or in combination.

Virtual reality-based paediatric interactive therapy system (PITS) for improvement of arm and hand function in children with motor impairment--a pilot study.

OBJECTIVE: Rehabilitation of upper-limb sensorimotor function in children with motor dysfunctions is primarily based on movement training. This study developed a virtual-reality based, paediatric interactive therapy system (PITS) that allows children to practice specific movements of the upper limbs with immediate feedback about their motor performance. METHODS: The system was tested on five children with motor dysfunctions over 3 weeks of training. Pre- and post-assessment was conducted before and after the training period. RESULTS: Results of the pilot study show improvements of hand function in the test scores (except one patient). Patient motivation was high and maintained over the course of the therapy sessions. CONCLUSION: PITS is an applicable VR-system which can be feasibly applied during the rehabilitation of children with upper limb motor dysfunctions. Further investigation is necessary to determine if the system provides significantly improved results compared to conventional therapies, both in terms of motor function outcomes and patient motivation.

Interactive visuo-motor therapy system for stroke rehabilitation.

We present a virtual reality (VR)-based motor neurorehabilitation system for stroke patients with upper limb paresis. It is based on two hypotheses: (1) observed actions correlated with self-generated or intended actions engage cortical motor observation, planning and execution areas ("mirror neurons"); (2) activation in damaged parts of motor cortex can be enhanced by viewing mirrored movements of non-paretic limbs. We postulate that our approach, applied during the acute post-stroke phase, facilitates motor re-learning and improves functional recovery. The patient controls a first-person view of virtual arms in tasks varying from simple (hitting objects) to complex (grasping and moving objects). The therapist adjusts weighting factors in the non-paretic limb to move the paretic virtual limb, thereby stimulating the mirror neuron system and optimizing patient motivation through graded task success. We present the system's neuroscientific background, technical details and preliminary results.

Callus mineralization following distraction osteogenesis of the mandible monitored by scanning acoustic microscopy (SAM).

BACKGROUND: Scanning acoustic microscopy uses ultrasound to analyse histomorphology of tissues with microscopic resolution and delivers data about physical properties of the specimen. MATERIAL AND METHODS: Bony consolidation was monitored by scanning acoustic microscopy in 12 embedded specimens of dog mandibles after distraction osteogenesis. Increasing mineralization was detected by measurements of acoustic impedance (Z). RESULTS: There was a strong correlation between acoustic impedance and time of consolidation. Measurements of the speed of sound (v) provided specific information about non-mineralized zones of the distracted area. Distribution of density in the distracted area could be reconstructed by using the measurements of acoustic impedance and speed of sound. CONCLUSION: The method seems suitable for studying bone remodelling qualitatively and quantitatively.