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Medical Rehabilitation (Med Rehabil) 2013, 17 (4), 29-36
29
The application of virtual reality in neuro-rehabilitation: motor
re-learning supported by innovative technologies
Zastosowanie rzeczywistości wirtualnej w neurorehabilitacji;
innowacyjne technologie wspomagające ponowne uczenie się ruchu
Paweł Kiper
1,2(A,B,D,E,F)
, Andrzej Szczudlik
2(A,D,E,F)
, ElŜbieta Mirek
3(D,E)
, Roman Nowobilski
2(A,E)
,
Józef Opara
4(A,E)
, Michela Agostini
1(B,F)
, Paolo Tonin
1(B,F)
, Andrea Turolla
1,5(B,F)
1
San Camillo Hospital IRCCS Foundation, Venice, Italy
2
Jagiellonian University Medical College, Krakow, Poland
3
University of Physical Education, Krakow, Poland
4
Academy of Physical Education, Katowice, Poland
5
The University of Sheffield, Sheffield, United Kingdom
Key words
Virtual reality, Robot-aided therapy, Motor learning, Rehabilitation
Abstract
The motor function impairment resulting from a stroke injury has a negative impact on autonomy, the activities of daily living
thus the individuals affected by a stroke need long-term rehabilitation. Several studies have demonstrated that learning new
motor skills is important to induce neuroplasticity and functional recovery. Innovative technologies used in rehabilitation al-
low one the possibility to enhance training throughout generated feedback. It seems advantageous to combine traditional mo-
tor rehabilitation with innovative technology in order to promote motor re-learning and skill re-acquisition by means of en-
hanced training. An environment enriched by feedback involves multiple sensory modalities and could promote active patient
participation. Exercises in a virtual environment contain elements necessary to maximize motor learning, such as repetitive
and diffe-rentiated task practice and feedback on the performance and results. The recovery of the limbs motor function in
post-stroke subjects is one of the main therapeutic aims for patients and physiotherapist alike. Virtual reality as well as robotic
devices allow one to provide specific treatment based on the reinforced feedback in a virtual environment (RFVE), artificially
augmenting the sensory information coherent with the real-world objects and events. Motor training based on RFVE is emerg-
ing as an effective motor learning based techniques for the treatment of the extremities.
Słowa kluczowe
rzeczywistość wirtualna, terapia wspomagana przez robota, uczenie się ruchu, rehabilitacja
Streszczenie
Upośledzenie funkcji ruchowych po udarze mózgu u wielu chorych ma negatywny wpływ na samodzielność i czynności życia
codziennego oraz wymaga długotrwałej rehabilitacji. Liczne badania wykazały, że uczenie się nowych umiejętności motorycz-
nych pobudza neuroplastyczność mózgu i umożliwia poprawę funkcjonalną. Innowacyjne technologie wykorzystywane w reha-
bilitacji wzmacniają możliwości treningu ruchowego poprzez dostarczanie informacji zwrotnej. Łączenie tradycyjnej rehabilita-
cji ruchowej z innowacyjną technologią poprzez wzmocniony trening umożliwia przyspieszenie ponownego uczenia się ruchu
i nabywania umiejętności funkcjonalnych. Otoczenie wzbogacone przez informacje zwrotną angażuje wiele zmysłów i stymuluje
pacjenta do aktywnej pracy. Ćwiczenia w otoczeniu wirtualnym maksymalizują efekt uczenia się ruchu poprzez powtarzające
się i zróżnicowane zadania oraz dostarczenie informacji zwrotnej w odniesieniu do działania i jego efektu. Innowacyjne techno-
logie rehabilitacyjne, zarówno terapia wirtualna, jak i urządzenia - roboty, pozwalają na specyficzne leczenie oparte na trenin-
gu z wykorzystaniem wzmocnionego sprzężenia zwrotnego w środowisku wirtualnym (Reinforced Feedback in Virtual Environment
The individual division on this paper was as follows: A – research work project; B – data collection; C – statistical analysis; D – data interpretation;
E – manuscript compilation; F – publication search
Article received: 31.03.2014; accepted: 22.04.2014
Please cited: Kiper P., Szczudlik A., Mirek E., Nowobilski R., Opara J., Agostini M., Tonin P., Turolla A. The application of virtual reality in neuro-rehabilitation: motor
re-learning supported by innovative technologies. Med Rehabil 2013; 17(4): 29-36
Internet version (original): www.rehmed.pl
Medical Rehabilitation e ISSN 1896-3250 © WSA Bielsko-Biała
INTRODUCTION
Rehabilitation of people with central
nervous system (CNS) injury is diffi-
cult and requires involvement of dif-
ferent specialists, the patient and their
family as well and the effect of the
rehabilitation are not always fully sa-
tisfactory for both. This is due to the
complex and diverse nature of reha-
bilitating function of the nervous sys-
tem. Which include various physio-
logical phenomena, from simple re-
flex regulation of internal organs
through a complex reflex action, to
complex processes of thinking and
other mental functions.
Stroke is a common disease of the
nervous system. In Poland, there are
about 75 000 new strokes per year,
mostly among people over 65 years
old
1
. Approximately 15% of patients
with ischemic stroke and up to 50% of
patients with hemorrhagic stroke die
within a month, usually during the
first two weeks of hospitalization.
Such a high mortality rate means
stroke is the 3rd highest causes of
death in adults, both in the world and
Poland
2
. Only 10% of patients after
a stroke do not have significant im-
pairment of mobility, sensory disor-
ders or cognitive disorders, and 40-
75% of patients after stroke are com-
pletely dependent
3
.
Both ischemic and hemorrhagic
strokes often affect regions of the
brain responsible for planning and
execution of movements. This means
that various movement disorders are
common and long-persisting symp-
toms of a stroke. Most are hemipare-
sis (75% of patients), aphasia and
apraxia. For this reason, patients with
stroke in many rehabilitation centers
represent the largest population of
patients
2
.
Rehabilitation, both in acute and in
chronic stage of stroke are often not
fully effective due to the insufficient
frequency and duration of rehabilita-
tion. Intensification of the rehabilita-
tion process in order to improve the
function of self-care, social activity
and the ability to work is now becom-
ing a priority.
A recent study on motor learning
and control provide new neurophysio-
logical information that can be trans-
ferred into functional therapy. Scien-
tific studies have shown that repeti-
tive, intense and random task prac-
tice lead to the modification of neu-
ronal structures
4
. In order to facilitate
the activation of brain areas and, con-
sequently, to improve motor control,
it could be beneficial to combine clas-
sical rehabilitation with innovative
computer technologies. Using the
adaptive capabilities of the nervous
system exercises should involve dif-
ferent senses and promote active pa-
tient participation. Besides the con-
cept of classical rehabilitation, which
we can understand as the direct work
of physiotherapists or rehabilitation
team with a patient, there are also
different rehabilitation techniques,
where the work of physiotherapists
mirrors certain technology, such as
a computer in a virtual therapy or ro-
botic devices. Innovative technologies
such as robotics and virtual reality
(VR) are being tested in neuroreha-
bilitation especially for hemiparesis
treatment.
Virtual reality through enhanced
feedback in virtual environment (RFVE)
contains the components needed to
maximize motor learning, such as the
practice of repeated and varied tasks,
feedback of performance and its ef-
fect which can increase motivation.
Neuro-rehabilitation and motor
learning through methods and
robotic devices
Difficulties in fully understanding the
pathological phenomena after brain
damage leads to the emergence of
a variety of therapeutic methods asso-
ciated with various theoretical models
of rehabilitation. Some of these tech-
niques are already used in clinical
practice, while others are still in the
research phases.
One of the techniques developed,
based on the principles of motor
learning, is the Arm Ability Training.
This technique was developed for mo-
tor rehabilitation of patients with mi-
nor hemiplegia, characterized by im-
paired coordination and precision of
motion
5
in which the deficit can be
determined by a precise kinematic
assessment
6
. Arm Ability Training has
been described on the basis various
functions in healthy subjects, such as
grip, reaching, stability and speed of
movement. In a randomized clinical
trial Platz et al. showed greater bene-
fits with this training method when
compared to classical physiotherapy,
and the result was an improvement in
performing activities of daily living
with the affected limb
5
. Arm Ability
Training is more focused on functional
disorders than on disability in accor-
dance with the principles of motor
learning which states that motor con-
trol and learning are modular
7
.
Another technique is Electromy-
ogram-triggered Neuromuscular Sti-
mulation arising from the theory of
sensorimotor integration, which as-
sumes that the undamaged areas of
movement can be recruited and
trained, in order to achieve efficient
movement according to two learning
principles of movement: repetition
and sensorimotor integration
8
. Some
studies have shown the effectiveness
of this method in the treatment of
stroke in the acute, subacute and
chronic stage
9
.
Another technique is Constraint-
Induced Movement Therapy (CIMT)
including the temporary immobilisa-
tion of the unaffected limb (6-10 hrs. /
Day) and requirement to use the af-
fected limb. Rehabilitation through
CIMT is a method that can be used for
patients after stroke and chronic
cerebrovascular disease. For the up-
per limb the methods includes using
Medical Rehabilitation (Med Rehabil) 2013, 17 (4), 29-36
30
– RFVE), zwiększając informacje czuciowe odpowiadające rzeczywistym zadaniom i przedmiotom. Trening ruchowy oparty na
RFVE daje także możliwość poszerzenia wiedzy na temat technik wykorzystywanych do poprawy czynności ruchowych niedo-
władnej kończyny.
induction of the affected limb for the
majority of day whilst at the same
time immobilizing the unaffected limb
for a period of two to three weeks. For
the lower limb there are different
techniques which do not require im-
mobilization of the unaffected limb,
but these are based on intense trai-
ning enriched with functional elements
of positive feedback. The method is
based on the assumption of restoring
the inter-hemispheric balance by re-
ducing the somatosensory stimuli
coming from the unaffected limb and
increasing the stimuli coming from
the affected hemisphere
10,11
. The the-
ory is based on the fact that the CNS
has plasticity and in response to
stimulation it could stimulate inten-
sive creation of new neuronal connec-
tions
12-14
. Numerous studies have re-
ported changes in cortical brain exci-
tability
12,14,15
and have shown signifi-
cant improvement and effects in pa-
tients in the chronic phase following
stroke
16,17
.
Another therapy is Mirror Box
Therapy, which involves placing the
paretic limb inside a ‘mirror box’, and
the unaffected limb in front of the
mirror. Seeing a reflection of move-
ment through the mirror means that
visual feedback is provided and the
brain reads them as an image of pro-
perly functioning limbs. In this way,
cortical maps are again remodeled.
Observation of physiological move-
ment increases excitability of the
brain areas responsible for movement
of the affected limb and induces sub-
jective impression of the biologically
correct movement. Due to the motor
activation caused by the mirror neu-
rons system, it is assumed that they
represent internal models as exam-
ples of planning movements. Studies
have shown that patients with stroke
who used mirror therapy presented
significantly greater improvements in
motor activity compared to the con-
trol group. The improvement persisted
even six months after therapy
2,18,19
.
For relearning movement there are
also mechanical or electronic devices
that can help in the reeducation of
motor function. The following devices
have found wide application in the
treatment of motor impairment. Ro-
bot-Aided Therapy is based on the
theory of sensory integration com-
bined with multisensory feedback
(visual, sensory, auditory)
20,21
. It is
based on the enhanced stimulus
coming from the paretic side of the
body as a result of intensive repetitive
exercises both active and passive.
Most of these devices are based on
a passive exercise helping to achieve
the movement initiated by the pa-
tient. In order to perform robot-aided
therapy several types of devices have
been developed such as:
•
The robot called the MIT-Manus,
which provides visual, tactile and
auditory feedback. The device has
shown in numerous studies benefi-
cial effects in upper limb motor
function in patients during the
acute and chronic phases
22
. MIT-
Manus uses two ranges of motion
allowing for intense exercise for the
upper limb.
•
The Rutgers Master II-ND Force
Feedback Glove allows patients to
exercise finger movements. The pa-
tient undergoing therapy receive
feedback (visual, sensory, auditory)
during the execution of motor
tasks. Besides the feedback a com-
puter system provides real time in-
formation on the speed, range of
movement and force of the move-
ment performed. In clinical studies,
the authors concluded that this de-
vices could improve the quality,
speed and fine dexterity movement
and that the use of this therapy can
complement classical rehabilitation
23
.
•
The Assisted Rehabilitation and
Measurement (ARM) Guide allows
the patient to perform exercises in
four ranges of movement. In addi-
tion it can control the position of
the patient's limb, which is placed
on the handle. The patient moves
the handle in order to perform the
specified task and receives real-
time visual feedback on movement
and force generation on the moni-
tor, and information about the posi-
tion of the limb, range of motion
and the following motor task. The
authors suggest that the primary
stimulus for recovery of functional
movement is based on repeated
movements
24
.
•
Mirror Image Movement Enhancer
(MIME) is a robotic device that al-
lows the execution of movements
in six ranges of movement, helping
or hindering the performance of
motor activity depending on the
task. The efficacy of therapy using
this robot has been confirmed in
clinical studies
25
.
•
ARMin is a half-exo-skeleton sup-
porting movements of the upper or
lower extremities. The position and
force of the movement is adjusted to
the current capacity of the patient
and the tasks are displayed on the
screen placed in front of subject
26
.
•
The Phantom 3.0 robot was tested
on adult healthy subjects in order
to study the function of the muscu-
loskeletal system. This robot can
provide feedback (visual, auditory,
sensory) and generate forces which
resist movement performance (Fi-
gure 1 a, b)
27
.
•
The prototype robot Tino is able to
provide feedback, both sensory and
visual, generated as a virtual image
and provide resistance to assist the
patient with the correct perform-
ance of the movement. The robot is
used to improve the function of the
fingers and the wrist. A pilot study
showed significant improvement in
hand function (Figure 2 a, b)
28
.
Similar types of robotic devices allow
patients to perform exercises bilate-
rally. Usually, they generate only sen-
sory feedback. The use of these kind
of robots is to reeducate lost automa-
tisms e.g. during walking.
Bilateral Arm Training involves the
use of the same exercise in real time
for both affected and unaffected limbs.
Clinical studies on bilateral upper limb
training carried out using fMRI (func-
tional Magnetic Resonance Imaging)
point to facilitate interhemispheric
balance and reduction of intracortical
inhibition between hemispheres, which
takes place probably through connec-
tions of the commissural fibres
29,30
. To
perform bilateral exercise different
devices are used such as:
•
BI-MANU-TRACK, which is a system
that allows exercises for forearm
supination and pronation and wrist
flexion and extension. The move-
ments are performed bilaterally
and the patient does not receive
feedback at any stage
31
.
•
BATRAC is a device that allows the
patient to perform rhythmic move-
ments and again it does not provide
any feedback. Patients undergoing
Medical Rehabilitation (Med Rehabil) 2013, 17 (4), 29-36
31
therapy with this robot can perform
flexion and extension of the shoul-
der and elbow. The effectiveness of
BATRAC device has been tested in
clinical trials and shows improve-
ments of movement activity
32
.
The most commonly used devices to
exercise the lower limbs are Lokomat
and Gait Trainer. Lokomat is an auto-
mated gait orthosis supporting move-
ment re-education. It generates a simu-
lated gait pattern for any segments of
the lower extremities. The use of
a robot allows precise performance of
repetitive movements required for
normal gait pattern. Gait re-education
helps to prevent the formation of
compensatory and pathological pat-
terns. Krishnan et al. tested the device
with patients after stroke, showing
a significant improvement with gait
33
.
Gait Trainer is, however, intended for
people who are not able to reach an
upright position and do not have the
required movements within the limb
or limbs. The patient is placed in
a harness, onto a platform, which elimi-
nates the risk of falling and reduces
the degree of difficulty. This device
does not provide feedback and per-
form only passive movements based
on the phases of the gait cycle (Figure
3 a, b)
34
.
Using the techniques described
above in order to relearn movement
are characterized by certain general
principles according to which the im-
provement is dependent on the amount
of exercise performed. The acquisi-
tion of new motor skills is only possi-
ble though obtaining feedback from
the environment and depends on the
amount of exercise
35
. The first princi-
ple states that learning is more effec-
tive when performed exercises are
separated by periods of rest between
repetitions (distributed practice) com-
pared to the situation when repetitions
are performed in one block (massed
practice)
36
. Despite the fatigue, the
effectiveness of the training was in-
creased linearly because of the inter-
ruptions between exercises
37
. The sec-
ond principle states that the introduc-
tion of differentiated tasks (variable
practice) improves the remembrance
of performs in relation to the tasks
always performed repetitively (constant
practice)
38
. Another principle demon-
strates the importance of randomly
choosing the quantity and type of
tasks (contextual interference) to be
tested in the random ordering of
n trials of x tasks (random practice).
This leads to a better performance of
each of the tasks than if a single task
were practiced alone.
The continuous interaction with the
external environment unconsciously
determines the efficiency of education
of many of our behaviors and habits.
The basis of this process is procedural
memory (motor memory), which is
produced in the form of the likeli-
hood of responses for specific stimuli.
Procedural memory is located in the
structures associated with the motor
system, especially in the cerebellum,
and basal ganglia (caudate nucleus),
which is the starting point cognitive
and perceptual learning and motor
efficiency
39
. Motor learning can be
Medical Rehabilitation (Med Rehabil) 2013, 17 (4), 29-36
32
Figure 1 a and b
A patient moves the arm over a slippery flat surface with the aim of completing the
set motor task
Figure 2 a and b
A robot-Tino prototype serves in the rehabilitation of the fingers and wrists
Figure 3 a and b
A patient in the course of re-education by means of the Gait Trainer device
defined as the ability to improve indi-
vidual movements or sequences of
movements through repetition and
interaction with the environment.
It remains to determine how the
above-mentioned techniques affect
the reeducation of motor function in
stroke patients. Studies of random
practice and massed practice, which
included a group of patients in the
chronic phase post stroke showed
better improvement of motor function
in the random practice
40
. Many diffe-
rent sensorimotor exercise strategies
can be added to the rehabilitation
program. It was shown that some
forms of feedback improve the effi-
ciency of simple movement learning.
Winstein et al. observed this when
testing the phases (acquisition, main-
tenance and re-acquisition of motor
tasks) of the learning process by per-
forming simple movements with en-
hanced feedback. Comparing a group
of stroke patients with a control group
of healthy subjects did not show any
difference in the acquisition of motor
functions related to the learning pro-
cess. However, individuals after stroke
(regardless of the delivery of the feed-
back) committed more errors in each
phase than those in the control
group
41
. The authors concluded that
a stroke in the sensorimotor area al-
ters the ability to control and correct
movement execution, but not the
ability to relearn motor tasks.
Virtual therapy and the process
of motor re-learning
Virtual reality is an innovative tech-
nology consisting of a high-end user-
computer interface that involves real-
time simulation and interactions
through multiple sensorial channels.
These sensorial modalities are visual,
auditory, tactile, smell and taste. The
computer based environment repre-
sents artificially generated sensory
information and allows individuals to
experience and interact with or within
three-dimensional (3-D) environments
42
.
The first virtual reality video arcade
was the “Sensorama Simulator” in-
vented by Morton Heiling in 1962.
This early virtual reality workstation
had 3-D video feedback, motion, color,
stereo sound, aromas, wind effect and
a seat that vibrated. The term Virtual
Reality was introduced by Jaron Lam-
ier in 1986, describing it as a set of
technological tools (PC software for
3-D interactive display) and tracking
devices for the recognition of the po-
sition and orientation of a subject,
linked to a PC that updates the image
in real time on the display
43
. Virtual
reality has a history of use in military
training, entertainment simulations,
surgical training, training in spatial
awareness and in psychology for pho-
bias therapeutic intervention
44
. Several
systems have shown the advantage of
hand and arm motor skills training
for stroke patients, and also showed be-
nefits in cognitive enhancements
20,45-48
.
Virtual Reality refers to the use of
innovative technology, with enhanced
feedback (auditory, visual, tactile) and
provides sensory information in a form
similar to those received from real
world objects and events
49,50
. Rehabili-
tation in a virtual environment is car-
ried out with a physiotherapist, where
the person supervising the exercises
controls the movements and posture
of the patient.
Performing the exercises in a vir-
tual environment patients try to fol-
low optimal movement patterns which
are demonstrated in real time in a vir-
tual scenario. This approach is condu-
cive to learning by imitation, and the
complexity of motor tasks can be
gradually increased to facilitate the
transfer into the real world the move-
ment patterns learned in the virtual
one
51
. Patients following a stroke can
improve the ability of movement
through systematic and intensive
exercises in the virtual environ-
ment
52,53
. The use of therapy using
virtual reality in clinical practice is
a relatively new approach for reha-
bilitation developed about a decade
ago and is still under assessment.
Conducted studies have shown that
virtual reality has a major impact on
improving mobility
54-57
. It was shown
that motor relearning can be more
effective in an environment with en-
hanced feedback. This technology al-
lows the creation of special settings
where human-computer interaction
is optimized.
There are several ways to realize the
visual interaction, with varying degrees
of immersion (i.e., virtual reality in-
teraction level). What determines the
sense of presence is the level of im-
mersion provided, which in turn de-
pends on the system used. According
to the differing levels of immersion it
is possible to specify two types of vir-
tual reality: immersive and non-im-
mersive. Immersive virtual reality is
able to create a high level of real
world simulation by producing a three-
dimensional computer-generated en-
vironment. This high level of immer-
sion is possible by using a display de-
vice (e.g. Head Mounted Display, HMD)
and completely isolates the user from
the external environment. These de-
vices are equipped with one or more
electromagnetic sensors determining
the body position, motion detection
and continuously transmit this infor-
mation to a computer which changes
the three-dimensional image within
real time
58
. One of the systems provid-
ing the highest level of immersion is
a Cave Automatic Virtual Environment
(CAVE), which displays the images on
the walls cubic room. The person in
the room wears glasses with an elec-
tromagnetic sensor and these deter-
mine position within the three-dimen-
sional space and with appropriate
software the image changes in real
time according to the position of the
patient’s head
59
.
Non-immersive virtual reality uses
monitor displays or wall projections
to produce a three-dimensional image.
Therefore the external environment
is not completely eliminated and the
person receives the impression of
a three-dimensional virtual world. This
can be likened to looking through the
windscreen of the car. One type of
non-immersive system is the Virtual
Reality Rehabilitation System (VRRS),
in which the movement is recorded
and presented in a virtual scenario on
the monitor or on a wall projection
(Figure 4 a, b)
42,53,55
.
The current performance of these
technologies has allowed one to mini-
mize the latency in the exchange of
signals, which have provoked discom-
forts due to interaction with the vir-
tual world, such as cybersickness (nau-
sea, vomiting, dizziness, headache, di-
sorientation)
59
.
The rehabilitation in virtual reality
is a human-machine interaction in
a 3-D virtual-world created by means
of a computer in real time. Within
Medical Rehabilitation (Med Rehabil) 2013, 17 (4), 29-36
33
this virtual world, the patient learns
to manage problematic situations re-
lated to his disorder. The possibility of
the sense of presence in a real world
through virtual reality is offered to
the patient, which should permit one
to transfer the acquired skills from
the virtual environment into the real
world. In fact, the aim is not to recre-
ate mechanically the same physical
reality, but to provide the better in-
formation necessary to realize tasks
with the same confidence level as used
in the physical environment.
Virtual reality therapy used for re-
habilitation provides high quality care.
The advantage of using a virtual envi-
ronment in rehabilitation is undoub-
tedly the possibility to automatically
record the results which allows moni-
toring of treatment progress. The
ability to capture motor tasks helps to
analyze the results. In addition, vir-
tual reality systems allow you to create
scenarios similar to the patient’s real
environment and generate real-time
feedback in various forms depending
on the motor task. Furthermore it
generates stimuli to facilitate the
movement re-learning without error.
Virtual reality as a presented in the
form of a game can motivate patients
to increase participation.
CONCLUSION
This review paper indicates that inno-
vative technologies, both virtual the-
rapy and robotic devices, are beneficial
for the treatment of post stroke pa-
tients. Virtual Therapy and robotics
are relatively new approaches to re-
habilitation, developed to provide
a higher level of task simulation than
conventional physiotherapy.
Previous studies have shown that
virtual reality training in the form of
RFVE can be used as a technique for
movement re-learning
45
. It has been
shown that treatment within a virtual
environment can be beneficial for
both the subacute and chronic phase
following a stroke
60
. It seems that the
capacity of the recovery process after
acute stroke is effectively enhanced
by the use of RFVE training
55, 61
.
Authors in some research projects
have combined non-immersive virtual
reality with robotic devices which as-
sist with the required movement.
Some studies indicate that neural
processes are not the same if the activi-
ties are performed within the real
world or within a virtual environ-
ment
62
. In a study Saposnik et al.
63
suggested that virtual reality is a safe
and potentially effective alternative
treatment for the treatment of hemi-
paresis following a stroke.
As mentioned above, virtual reality
encompasses a range of innovative
technology, which artificially gene-
rates sensory information in a form
that people perceive as similar to the
real ones. The basis for most virtual
therapy systems is a three-dimensional
visual simulated environment pre-
sented on a monitor or wall projec-
tion. To experience realistic explora-
tion and interaction computers must
upload new images rapidly enough to
give the impression of real time reac-
tion. It is important that simulated
objects and events can be felt not only
in a visual sense, but they can interact
with the user, as if they were real. The
psychological impact of exploration
and interaction with a virtual envi-
ronment means that you have some
sense of ‘presence‘ in a simulated
world. This feeling of presence is
probably the result of the experience
of virtual reality.
Perhaps the sense of presence is
caused by actions that occur in the
simulated world perceived as real fee-
ling. It is not assumed that the ability
acquired in virtual reality will replace
real actions but would provide better
information to perform real tasks. In
relation to stroke patients virtual trai-
ning should ideally stimulate motor re-
learning and motor skills necessary to
perform activities of daily living.
Virtual reality technology is also
used for the rehabilitation of the pa-
tient at home using the internet,
called tele-rehabilitation. The patient
receives information on how to per-
form the exercises from a physio-
therapist located in the hospital, and
on the computer in the patient’s home
shows the required task. Continuous
contact with the patient is ensured
through a webcam and voice messa-
ging. Tele-rehabilitation may be the
solution to provide continuous reha-
bilitation and reduce the cost of hos-
pitalization of stroke patients, at the
same level as hospital based virtual
reality
64,65
. Piron et al.
45,64
studied the
use of virtual therapy both in clinical
settings and in the patient's home. In
these studies, both patient groups
achieved better results if they per-
formed virtual therapy when com-
pared to conventional treatment
45,64
.
Currently, integrating virtual reality
technology into rehabilitation at home
is under development.
The main benefit of using virtual
therapy in stroke rehabilitation is to
engage people in a simulated event
and eliminates the limitations asso-
ciated with disability, in addition to
being able to safely perform the task.
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Address for correspondence
Paweł Kiper, PhD PT
Fondazione Ospedale San Camillo IRCCS
Dipartimento di Neuroriabilitazione
Laboratorio di Cinematica e Robotica
via Alberoni 70
30126 Venezia, Italy
tel.: +39 0412207214
e-mail: pawel.kiper@ospedalesancamillo.net
Medical Rehabilitation (Med Rehabil) 2013, 17 (4), 29-36
36
