State of the Science Symposium Virtual Reality and Physical Rehabilitation: A New Toy or a New Research and Rehabilitation Tool? Emily A. Keshner Department of Physical Therapy College of Health Professions and Social Work Department of Electrical and Computer Engineering College of Engineering Funded by the National Institutes of Aging and National Institutes of Deafness and Communication Disorders of the National Institutes of Health.
What questions do we ask about clinical treatment and research? 1. Are we influencing the actions of the brain? 2. Is there learning? 3. Does the amount, kind, frequency of practice matter? These are the same questions that need to be asked about virtual reality when used for rehabilitation
Traditional Outcomes Measures Increased frequency of participation Activity logs Subjective reports Sensory and Motor Clinical Tests Manual muscle testing Reflex latencies Sensory identification Timed Get Up and Go A common weakness in all of these measures is the absence of multitasking
Is multitasking important for rehabilitation?
You don t need to worry about where to focus attention when you are moving in an environment that does not distract from the goal of the movement
BUT, in natural environments there are many things that may take your attention away from your actions...
Immersion in a virtual environment provides conflicting sensory demands like in a natural environment Gravitational Vector Visual Motion VECTION Otolith Signal Visual Signal Perception of Tilt visual scene CCW perception of CW self-motion otolith vector tilt CCW Keshner and Kenyon, 29
Incorporating other technologies can make demands of the Virtual World even more realistic
How can we evaluate Virtual Reality as a Rehabilitation Tool? 1. Are we influencing the actions of the brain? 2. Is there learning? 3. Does the amount, kind, frequency of practice matter? 4. Can we use VR for rehabilitation and training?
Virtual Reality images generate whole body actions during realistic tasks Laboratory for Innovations in Rehabilitation Technology, University of Haifa, Israel (Director: Tamar Weiss, OT, PhD)
VR influences perception of environmental demands A 3-dimensional, complex texture mapped, stereo visual scene that elicits a strong sense of presence in the observer. Virtual Environment and Postural Orientation Laboratory Temple University, USA, Emily Keshner PT EdD, Director
Wand tilt angle (Degrees) Head tilt angle (Degrees) Side-to-side center of pressure (cm) Wand tilt angle (Degrees) Head tilt angle (Degrees) Side-to-side center of pressure (cm) Visual Attention affects Spatial Orientation WAND HEAD COP 8 S5 6 4 CCW (Roll) 2-2 CW -4 8 S5 6 4 CCW (Roll) 2-2 CW -4 8 6 4 2-2 -4-6 S5 CCW (Roll) CW -6-6 -8 A A A 8 S1 6 4 2-2 -4-6 8 S1 6 4 2-2 -4-6 8 6 4 2-2 -4-6 -8 S1 B B B 8 6 4 2-2 S12 8 6 4 2-2 S12 8 6 4 2-2 -4 S12-4 -6 2 4 6 8 1 12 14 16 Time (Sec) QSEO Roll -4-6 2 4 6 8 1 12 14 16 Time (Sec) QSEO Roll -6-8 2 4 6 8 1 12 14 16 Time (Sec) QSEO Roll C C C Keshner et al. Cyberpsych, 26
Motion of the Visual World Can Influence How we Plan our Movement S7 Random Dot Pattern ankle trunk head -5 S1 Great Hall of Vection 3 S8-5 S3 Forward Left Right Backward -3.5-2.5-1.5 -.5.5 x-position (ft) 3-3.5-2.5-1.5 -.5.5 x-position (ft) Keshner and Kenyon 2
Evaluating the Value of Virtual Reality as a Rehabilitation Tool 1. Are we influencing actions of the brain? Yes Motor Planning and Perception 2. Is there learning? 3. Does the amount, kind, frequency of practice matter? 4. Can we use VR for rehabilitation and training?
Benefits of a virtual play rehabilitation environment for children with cerebral palsy Neural changes in the affected limb seen with fmri after VR therapy. After VR therapy the child was able to spontaneously perform Reaching Self-feeding Dressing which were not possible before the intervention. You et al. Developmental Medicine & Child Neurology 25
Joyce Fung, PT, PhD Laboratory Jewish Rehabilitation Hospital, Montreal, Canada
Habituation to Virtual Environments Fung et al. CyberPsych Behav, 26
RESULTS of TRAINING in VR With practice, patients increased gait speed to match task demands and adapted their gait to fit with changes in physical terrain. However, they did not develop the ability to anticipate and avoid collision with obstacles. Patients learned to change their movement but did not develop new cognitive planning skills necessary for acting in new environments.
Evaluating the Value of Virtual Reality as a Rehabilitation Tool 1. Are we influencing the actions of the brain? Perception and Motor Planning 2. Is there learning? Yes, error feedback generates adaptive motor behavior 3. Does the amount, kind, and frequency of practice matter? 4. Can we use VR for rehabilitation and training?
Virtual grocery stores are being used for navigation and socialization skills The Multi-User Virtual Action Planning Supermarket Weiss and Klinger, 29 Trajectory while shopping for items by a user with no impairment. A typical trajectory of the same shopping task by a client with Parkinson's Disease
Training Hand Function Alma Merians PT,PhD and Sergei Adamovich PhD, UMDNJ Combine virtual environments with a haptic master to provide practice for grasping, reaching, or both grasp and reach with assistance or resistance
Stroke subjects after practicing approximately three hrs/day for 8 days demonstrated a more normalized trajectory even without haptic assistance Adamovich et al. 29
Evaluating the Value of Virtual Reality as a Rehabilitation Tool 1. Are we influencing the actions of the brain? Perception and Motor Planning 2. Is there learning? We learn through error feedback generating adaptive behavior 3. Does the amount, kind, and frequency of practice matter? To get functional carryover, learned movement must be incorporated into complex motor behaviors The range of behaviors is still to be determined. 4. Can we use VR for rehabilitation and training?
A benefit of VR is standardized and individualized intervention within a purposeful context http://en.wikipedia.org/wiki/projection_augmented_model
Angular deviations Elderly adults and patients with neurological deficit are visually dependent Vertical Alignment young elderly stroke 2 15 1 5 1 2 3 4 trial Can we utilize this visual dependence to influence and evaluate motor relearning?
Participants 12 elderly (57-81 yrs) 17 patients with right hemiparesis (51-71 yrs) all community ambulators with intact sensation Scene was moved in upward or downward pitch at 3º or 45º/sec 3 deg deg.1 deg/sec Pre-incline period 5 s 3 s 3 s Incline period SCENE ON Post-incline period
Healthy Young Adult s COM is Sensitive to Velocity and Direction of Visual Motion
COM (mm) Healthy Elderly Patient with Stroke Anterior 5 3 1-1 -3-5 5 3 1-1 -3-5 dark up 45 deg/s up 3 deg/s -7 15 3 45 6 5-7 15 3 45 6 5 3 3 1-1 1-1 Posterior -3-5 -7 15 3 45 6 Time (sec) -7 15 3 45 6 Responses reflecting direction and velocity of the virtual scene suggests that VR is a feasible training tool. -3-5 dark down 45 deg/s down 3 deg/s
Balance Training on a Moving Platform in a VR CAVE Trained for a 2 week period In the dark Increased sensitivity of platform each day up to 2 times COM motion Patient instructed to focus on position of hips and knees.
Medial-Lateral(cm) Medial-Lateral(cm) Medial-Lateral(cm) Postural Sway Decreases with Practice 5 4 COP Pre-Training 73 yo female who falls 1 years post-onset of bilateral vestibular deficit an active, community dweller no other significant health problems 3 2 1-2 -15-1 -5 5 1 15 Anterior-Posterior (cm) 5 COP Post-Training 5 COP Post-2 weeks 4 4 3 3 2 2 1 1-2 -15-1 -5 5 1 15 Anterior-Posterior(cm) -2-15 -1-5 5 1 15 Anterior-Posterior(cm)
Effect of Training on Individuals with Head Injury (e.g., concussion, stroke) Used visual motion and platform motion to produce instability Trained with plantar vibration in the dark to enhance stabilization Patient with Stroke Trunk Motion (COM) Body Sway (COP)
VR is a Research and Rehabilitation Tool Virtual reality is a motivating and safe tool for rehabilitation purposes Virtual reality can be used both as an intervention and an outcome measure of rehabilitation gains Dosages for applicability to motion in the physical world and accurate transfer of training need to be further verified
COLLABORATORS Electronic Visualization Laboratory University of Illinois at Chicago Robert Kenyon Kalpana Dokka Virtual Environment and Postural Orientation Lab College of Health Professions and Social Work Ravi Buddharaju F. Jay Haran Richard Lauer Jill Slaboda Justin Shi Yun Wang This research was funded by the National Institutes of Aging (AG16359) and National Institutes of Deafness and Communication Disorders (NS2249, DC1125, and DC5235) of the National Institutes of Health and by a NIDRR Switzer Fellowship.