Virtual-reality research opens doors for post-stroke rehabilitation
By Stefanie Kurtz
Technology is an expanding world that seems to grow by leaps and bounds every day. Particularly in health care technology has become the cornerstone of advancement. In recent years, virtual reality has become more mainstream when it comes to health care and the field of rehabilitation is no exception.
At the Fourth International Workshop on Virtual Rehabilitation (IWVR 2005) held in Catalina Island, CA, in September, a concept developed by engineers from the Department of Electrical and Computer Engineering at Rutgers University in Piscataway, NJ, along with a physical therapist from the Department of Developmental and Rehabilitative Sciences at the University of Medicine and Dentistry of New Jersey (UMDNJ) in Newark, was presented.
The "Rutgers Arm" is a virtual reality-based approach to upper-extremity rehabilitation in individuals who have suffered a stroke. The computerized system is the result of the group's collaborative research into improved post-stroke, upper-extremity rehabilitation.
Technology in Rehab
As I sat in a restaurant last week, I glanced across the room at an older couple sitting in a booth by the window. The booth was equipped with a computer game where you stack multicolored bubbles onto one another to eliminate rows, a la Tetris. While her husband finished his meal, the woman played the game, cheering quietly for each little success. The husband, who seemed to have tremor from Parkinson's disease, cheered right along with her.
I watched the two of them and thought to myself, 'Why does technology allow for this woman to play a videogame in a booth at her local diner on a Sunday morning, but yet she probably can't share a peaceful slow dance with her husband?'
Although we haven't gotten to that point yet, it's not for lack of effort. Researchers are working hard to improve the quality of life for individuals living with varying conditions, like Parkinson's or stroke. Technology continues to play a big role in the effort. More specifically, virtual-reality technology has, in recent years, become more and more prominent among rehabilitative technologies. Research has been conducted for individuals with everything from balance disorders, to those with ankle sprains, or to children with cerebral palsy.
For individuals who had a stroke, virtual reality technology may just be turning a corner. Dr. Grigore Burdea, an inventor and professor of computer engineering from Rutgers University, joined Alma S. Merians, PhD, PT, professor at UMDNJ in the doctoral programs in physical therapy, several years ago and put together a team to develop a hand device to assist individuals with stroke in upper-extremity rehabilitation. Today, that system has been morphed into an arm apparatus, complete with challenging tasks and innovative technology.
The Rutgers Arm
Dr. Merians, professor and department chairperson for the department of developmental and rehabilitative sciences at the School of Health-Related Professions at UMDNJ, has many years of experience in the treatment of people with neurological disabilities. She has been involved with the development of the Rutgers Arm from the beginning.
Still in its early stages, the Rutgers Arm has been tested for a period of five weeks on a subject in the chronic phase post stroke, under both local and telerehabilitation conditions. Improvements in computerized measures as well as Fugl-Meyer test scores showed both better arm motor control and increased shoulder range of motion.
The Rutgers Arm system consists of several components. It is secured on the individual's arm and uses two 3-D trackers. The trackers record the position of the wrist and shoulder joints while the patient does each task. Interfaced with the device is a PC with simulation game software.
The patient's arm rests on a padded surface on a low-friction table. The most recent development in the use of this device is the incorporation of a tilting, so the patient works against gravity for increased exercise difficulty.
The patient, when fitted with the Rutgers Arm, is given tasks to do on the PC using the affected arm. The games, along with the 3-D trackers, keep track of the levels at which the patient is performing, as well as the progress he has made.
"The reason for using this virtual reality environment for training is that it harnesses the principles of neuroplasticity and motor learning. As we've learned over the past several years, in order to make changes in the brain you have to develop a skill and practice with that skill for many, many repetitions," explained Dr. Merians.
Currently the device is programmed to run two games. The first, called "Pick and Place," involves the patient placing his virtual hand over a ball that is shown on screen and moving the ball toward a target over a prescribed trajectory also shown on the screen.
"We have them move it forward and back, in adduction and abduction and in a diagonal movement," said Dr. Merians. "We take an initial range of motion and then we have computer algorithms that keep increasing the range the patient has to work in. We can then give the patient feedback about the trajectoryis it smooth? Is it appropriate?"
The second game, called "Breakout3D" is an adaptation of the well-known arcade game "Breakout." In this game, the patient has an on-screen paddle and ball. Using the paddle, the patient bounces the ball dynamically into a set of bricks to make them disappear, one at a time. The goal of the game is to make all of the bricks disappear with a fixed number of balls. "That is to practice velocity of movement and eye-hand coordination. We can adapt the game for the patient based on the speed of the ball, and the size of the paddle." Dr. Merians said.
Why VR Games
Virtual-reality games provide a motivating way to get people moving and increase mobility. For patients, repetitive tasks needed to improve functional skills can become boring and frustrating. For therapists, it is difficult to work with a patient over a long enough period of time and to really monitor each repeated motion. Virtual-reality simulations can provide an environment in which patients can repetitively practice motor skills and in which their progress can be objectively monitored.
The Rutgers Arm, according to Dr. Merians, has the potential to provide an appropriate therapeutic environment and help both the patient and the therapist. "The games encourage patients to practice," said Dr. Merians. "People get hooked on computer games and are perfectly willing to practice something over and over again in a computer environment that they wouldn't do in a real-world environment. Then we can use motor-learning principles in terms of giving them feedback visual, auditory and numeric feedback. They get scores, trajectories, even (virtual) applause."
While the Rutgers Arm is not meant to replace one-on-one sessions with a therapist, Dr. Merians foresees a bright future for virtual reality post-stroke as a complement to therapy. "I envision that these types of devices will be used to augment existing therapy in a clinical situation," she said.
In a clinical setting, the PT would set the patient up with the device and customize the parameters based on the patient's need. The patient can then do the tasks while the PT can work with other patients. "It would be under the control of the physical therapist but it would augment their therapy," said Dr. Merians.
Future of the Rutgers Arm
The Rutgers Arm was well received at the virtual rehabilitation conference in September. Currently, Drs. Merians and Burdea are looking toward what's next for the Rutgers Arm. "At this time we have to work with patients who have completed their therapy because this is a new device," explained Dr. Merians. "We plan to now test the newer device (with the shoulder 3-D tracker and the tilting table) and then we plan to test it on more subjects."
In the long term, the team behind the Rutgers Arm would also like to further explore the potential for the device in a home setting. "In this current clinical environment it is very difficult to provide the intensity and amount of treatment needed to make changes in the brain post-stroke. PTs have too many patients. They can't spend an hour or two hours during one treatment session with one patient," explained Dr. Merians.
In a clinical situation, the Rutgers Arm certainly shows promise, but telerehabilitation may also be a feasible option for patients who use the device in the future. "We've tried telerehabilitation between our universities (30 miles away) but we have not yet used it at home. Right now we can visualize what's happening. I think at this point you can't put it with a patient and not supervise," said Dr. Merians. "When we tested it in the university setting, the patient's success in the games did not diminish. I think it's pretty promising."
The next Workshop on Virtual Rehabilitation (IWVR 2006) will be held in August in New York. Those interested can get more details from www.iwvr.org
Stefanie Kurtz is on staff at ADVANCE and can be reached at skurtz@merion.com http://physical-therapy.advanceweb.com/common/EditorialSearch/printerfriendly.aspx?AN=PT_05nov21_ptp25.html&AD=11-21-2005