Motor recovery the virtual way

One of the major goals of rehabilitation is to make quantitative and qualitative improvements in daily activities in order to improve the quality of independent living.

Three determinants of motor recovery are early intervention, task-oriented training, and repetition intensity while a major objective of rehabilitation is to identify the means to provide repeated opportunities for tasks that involve multimodal processes (different sensory modalities including vision, haptics, proprioception, audition) and that further enable increases in function.

Carr and Shepherd focus on motor relearning where relearned movements are structured to be task specific.

They suggest that the practice of specific motor skills leads to the ability to perform the task and that motor tasks should be practiced in the appropriate environments where sensory inputs modulate their performance. The functional relevance of the specific environmental context has been specifically addressed by Keshner and colleagues as it relates to posture control. These authors have shown that specific postural responses differ between paradigms where isolated individual control pathways are manipulated (i.e., visual, vestibular, somatosensory pathway) as opposed to within a functionally relevant context where information from multiple pathways is available.

The successful integration of virtual reality into multiple aspects of medicine, psychology, and rehabilitation has demonstrated the potential for the technology to present opportunities to engage in behaviors in challenging but safe, ecologically valid environments while maintaining experimental control over stimulus delivery and measurement. Moreover, in VR, the user (patient, therapist) interacts with a multidimensional, multisensory computer generated environment, a virtual environment, which can be explored in real time.

Virtual reality also offers the capacity to individualise treatment needs while providing increased standardisation of assessment and training protocols. In fact, preliminary evidence indicates that VR provides a unique medium where therapy can be provided within a functional, purposeful and motivating context and can be readily graded and documented. Several features distinguish virtual environments from other forms of visual imaging such as video and television.

A key feature of all VR applications is interaction. Virtual environments (VE) are created that allow the user to interact with not only the VE but also with virtual objects within the environment. In some systems, the interaction may be achieved via a pointer operated by a mouse or joystick button. In other systems, a representation of the user's hand (or other body part) may be generated within the environment where movement of the virtual hand is “slaved” to the user's hand allowing a more natural interaction with objects. Finally, while many applications of VR allow the user to control the viewpoint on the screen, third-person views or images of the users themselves that appear as players in the environment also provide the opportunity for interaction with the VE.

A broad range of visual interfaces are used to create varying degrees of immersion in a VE ranging from conventional desktop monitors to head mounted displays.

Increasingly complex, fully immersive VR systems, such as the Cave Automatic Virtual Environment (CAVE) developed at the University of Illinois at Chicago, provide the illusion of immersion by projecting stereo images on the walls and floor of a roomsized cube. Several persons wearing lightweight stereo glasses can enter and walk freely inside the CAVE. A head tracking system continuously adjusts the stereo projection to the current position of the leading viewer. In order to integrate the movement of the user with that of the VE and virtual objects, user position and motion must be tracked so that virtual images can be updated in real-time. Motion tracking approaches include colour subtraction technology, video frame subtraction as well as magnetic and infrared tracking devices. Technical advances in the development of these interfaces have minimised the once lengthy lag times responsible for some of the earlier reports of cybersickness.

To date, rehabilitation applications have primarily used visual and auditory sensory input while the addition of haptics is less developed. Haptic interface devices including gloves, pens, joysticks and exoskeletons provide users with a sense of touch and allow the user to feel a variety of textures as well as changes in texture. There is increasing evidence that haptic information is an effective addition towards the accomplishment of certain treatment objectives such as increasing joint range of motion and force. Haptic information has also been identified as a significant signal for improving a subject's performance in more difficult tasks. For example, Shing and colleagues report a specific benefit of adding haptic information to an upper extremity movement when the difficulty of the task, in this case a 3D pick and place task, was high. Integration of visual and haptic interfaces with motion tracking allows the user to become immersed in three dimensional virtual environments, including three dimensional sound, and virtual objects that can be picked up, manipulated, and even felt with the fingers and hands.

Another cardinal feature of virtual reality is the provision of a sense of actual presence in, and control over, the simulated environment. The sense of presence has been defined as the feeling of being in an environment even if one is not physically present and resulting in behavior that is congruent with the subject's situation in the environment. Early studies relied on questionnaires to characterise presence within a virtual environment with more recent work suggesting that physiological measures including heart rate and galvanic skin response provide important information about user immersion.
Movement elicited and generated in virtual reality applications

One important consideration with the application of virtual reality and movement in virtual environments is the behavior or movement characteristics of subjects in virtual environments. Recent work by Feldman and colleagues specifically compared movements made with or to virtual objects in a VE to movements made with or to real objects in real environments.

 Virtual representations of the hand were obtained by combining a fiber optic glove with a prehension force feedback device. Orientation of the hand in the VE was achieved using an electromagnetic tracker while kinematic data of the arm and trunk were recorded as the participant reached separately to real and virtual targets. Minimal movement differences in spatial and temporal kinematics of reaching in healthy adults were identified and included the amount of terminal wrist and elbow extension as well as timing of maximal grip aperture. There were no differences in movement characteristics between the real and virtual task in participants with hemiparesis.

The authors suggest that VR is similar enough to reality to provide an effective training environment for rehabilitation. In contrast, we have demonstrated significant differences between functional lateral reach performances when performed in the real environment versus in a virtual environment delivered on a flatscreen. The VR technology, VIVID Group's IREX system, provided participants with a third-person view of the users themselves in the virtual environments where they acted on virtual objects. Both young and old adults reached significantly further when virtual objects were presented in the VE compared to when reaches were made to real objects presented in the periphery.

Lateral stability is crucial for performance of many weight-bearing tasks including turning, transferring, and stepping onto a stool while controlling a reach made as far as possible to the side requires regulation of the position of the centre of mass within the limits of stability. We proposed that embedding the reaching task within a VR application may have resulted in shifting attention away from the potential for loss of balance, whereas focusing attention on balance, such as in the realenvironment, may have resulted in increased fear of destabilisation and underestimation of true ability.

Improving the functional abilities of patients is commonly achieved by using tasks of increasing difficulty in combination with physical and/or verbal guidance of the patient's movements or actions. Thus, integrating the means to modulate the level of difficulty within a VR task is of crucial importance. A virtual reality system (VIVID GX) was used to provide independent leisure opportunities to adults with cerebral palsy and severe intellectual disabilities who were nonspeaking and who used wheelchairs for mobility. The participants demonstrated an exceptional degree of enthusiasm during the VR experiences reacting with appropriate, goal-oriented responses. However, a small number of participants clearly displayed involuntary movement synergies, increased reflexes and maladaptive postures, which were attributed to the level of task difficulty. The ability to change the virtual environment relatively easily, to grade task difficulty and to adapt it according to the patient's capabilities are important advantages of VR, since these features are essential to cognitive and motor remediation.

Transfer of training

Central to the issue of virtual environments as a training medium is the issue of transfer of training; does task improvement or learning transfer reliably from a VE to a real environment? Virtual environments and VR interventions should not only be used to augment current ability or to provide exposure to "other" therapeutic possibilities, but importantly to demonstrate distinct carryover to real-life functional tasks. One major challenge is identifying effective and motivating intervention tools that enable transfer of the skills and abilities achieved during rehabilitation to function in the "real" world.


Although the majority of VR environments that have been developed for assessment to date focus on daily living skills such as meal preparation, spatial memory and cognitive function, specific applications have been developed for assessment of upper and lower extremity motor function, balance and locomotion. For example, two separate assessment approaches using the PHANTOM haptic interface, a six degree of freedom measuring device for positional input that provides feedback force in translation and rotation have been developed. Broeren et al used a relatively simple task requiring the user to reach for, grasp and move the visual representation of the device from a home position to nine separate locations in the visual field. Preliminary data suggest that this is a potential tool for identifying specific deficits of movement such as timing or accuracy that vary across patients. A more complex use of the technology, labyrinth navigation, has been used to isolate more subtle aspects of movement in patients with neurological disease including tremor amplitude and frequency, movement control, and speed of advancement through the labyrinth.

Assessments can be developed using VR technologies that will provide objective, repeatable and quantitative results. Standardised instructions, non-varying environmental cues, tasks and feedback can be achieved. In the extreme condition, interactions are limited to those between the patient and a virtual assessor. Since the devices are programmable, varying the complexity of assessment tasks is relatively trivial allowing for batteries of simple and more complex tasks to be developed. For example, an upper extremity assessment scale may include tasks requiring self-selected motion as well as responses to force perturbations permitting assessment of feedback limb control.

Development and incorporation of virtual reality applications in rehabilitation may increase the possibility of stimulation and interaction with the world with potentially little or no increase on the demands of staff time.

Virtual reality may provide interesting and engaging tasks that are more motivating than formal repetitive therapy. In fact, our recent experience comparing participant perceptions of exercise programmes strongly suggest there is added benefit with VR compared to a conventional programme.

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