Can Virtual Reality Aide in Post-Stroke Rehabilitation?

Introduction

Virtual Reality (VR) has emerged as a popular technology that has made its way into the healthcare field through its use as a rehabilitation aid for stroke patients. 

Virtual Reality (VR) utilizes cutting-edge, 3D imaging technology to create immersive experiences that engage the user in simulated environments [1]. This technology emerged into mainstream media around the 2010s and has become popular among the public. Despite its traditional association with gaming, this technology found its way into the rehabilitation world. This innovative approach has the potential to make rehabilitation more engaging and accessible, ultimately increasing patient recovery outcomes [1]. Nevertheless, how does VR work to rehabilitate patients, and has it been proven successful? 

History of Virtual Reality

VR is a significant advancement in modern-day technology, opening the door to numerous possibilities. The U.S. Food and Drug Administration (FDA) defines VR as a virtual world that creates a simulated, immersive, and interactive experience for the user [2].

The first recorded use of VR in healthcare dates back to the late 1990s, when it was used to treat post-traumatic stress disorder (PTSD). Around the same time, surgeons began to utilize VR as a tool to navigate and plan complex surgeries [3]. These first instances of VR in healthcare inspired a broader use of the technology, leading to its application to several different medical purposes, such as stroke rehabilitation [1].

What is a Stroke? 

Stroke continues to be a rising global health issue and is the leading cause of long-term disability worldwide. A stroke occurs when blood flow is obstructed (ischemic stroke) or sudden bleeding in the brain (hemorrhagic stroke) [4]. According to the Centers for Disease Control and Prevention (CDC), in the United States, someone experiences a stroke every 40 seconds, and someone dies from a stroke every 3 minutes [4]. Strokes often lead to debilitating long-term complications, such as paralysis of the lower or upper extremities, loss of speech, reduced comprehension, and loss of bowel and bladder control. Approximately 35% of stroke survivors who undergo rehabilitation experience motor impairments in their legs, while 20-25% are unable to walk without assistance [5].

Overall, stroke treatment methods and technology must continue to advance to increase stroke recovery rates and outcomes. For this reason, scientists and health professionals hope to witness a considerable advancement in stroke rehabilitation soon using VR.

Traditional Post-Stroke Treatment 

Immediate medical intervention is crucial to reduce the risk of permanent disability, as each untreated minute leads to brain cell death due to lack of oxygen [6]. Traditionally, tPA (generically named Alteplase), a clot-dissolving medicine, is administered to stroke patients intravenously. This medicine effectively dissolves blood clots that are blocking blood flow to the brain [7]. When Alteplase is administered within 3 hours after a stroke, tPA can help to restore blood flow to the brain and therefore lower the risk of damage [7]. After emergency care, the focus shifts to helping the patient regain lost function and maintain independence. Healthcare providers assess the level of disability after a stroke using various physical and mental tests, along with neuroimaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI) [8]. 

Rehabilitation includes a multidisciplinary team, including physical, occupational, and speech therapists. As a majority of stroke patients suffer from weakness or paralysis in their extremities, physiotherapy is essential for recovery, aiming to improve the patient’s gait and ability to perform activities of daily living (ADLs) [9]. Gait is the pattern of how a person walks, and ADLs include tasks like personal hygiene, cooking, dressing, eating, and ambulating [9]. Generally, the end goal of rehabilitation is to work towards having the patient effectively perform these tasks self-sufficiently.

When it comes to regaining motor control, physical therapy can be a long and difficult process. Studies show that even with six months of therapy, only about 50% of patients with lost upper limb function can regain some functionality [6]. Additionally, negative emotions and a lack of engagement will often cause a disconnect between the patient and their rehabilitation, therefore significantly slowing any possible recovery. Studies show that positive emotions correlate with an increased rate of functional recovery post-stroke [10]. Therefore, rehabilitation must be fun, engaging, and motivating for patients. 

Virtual Reality in the Rehabilitation Sphere

The emergence of VR in healthcare has revealed its potential to enhance traditional rehabilitation methods. Health professionals believe that VR uses several neurological mechanisms to stimulate high-repetition movement and enhance motor recovery by providing immediate feedback and measuring brain function [11]. A key aspect of VR treatment is the brain’s ability to form new neural connections, commonly referred to by professionals as neuroplasticity [12]. Neuroplasticity allows patients to regain functions previously lost due to stroke, and by applying this process to VR treatment, researchers can better understand how exactly VR works to improve stroke recovery. With the utilization of VR, researchers can provide targeted cognitive stimulation in a meticulously controlled environment, which will ultimately improve the patient’s neural adaptation and recovery [12].

Healthcare providers can also apply VR to specific aspects of treatment. For example, Gait-Triggered Mixed Reality (GTMR) is a multisensory feedback tool for lower-limb rehabilitation [1]. This technology adapts to the user, allowing providers to challenge their patients in a way that is still achievable. Studies using the Wii Fit–a VR-based exercise game designed by Nintendo–demonstrate VR’s effectiveness in gait rehabilitation, showing lasting improvements in walking and balance [9]. Similarly, the Rehabilitation Gaming System for aphasia (RGSa) promotes lasting improvements in language recovery through syntactic training [1]. 

Studies also prove that VR fosters engagement and offers an immersive environment for the patient, which is paramount to successful treatment. A 2021 study qualitatively recorded the experiences of stroke survivors with an immersive treadmill-based VR game [13]. After interviews with five clinicians and stroke patients, they concluded that a fully immersive treadmill-based VR game is acceptable and potentially beneficial for gait rehabilitation. The participants stated they were very motivated and proud of their achievements via VR’s ability to provide a safe and engaging therapeutic environment [13]. 

Other studies highlight VR’s potential in early rehabilitation stages [1]. For example, in a 2020 study, researchers assessed three stroke patients who had lost upper limb movement over two months, using VR to measure gait and fall risk. Researchers assessed gait using the Timed Get Up and Go Test, which records how long it takes a patient to get up from a chair, walk three meters, and sit back down. The study concluded that patients who participated in VR therapy had a lower fall risk [14]. In comparison, researchers measured fall risk using the Activities-Specific Balance Confidence Scale. Results demonstrated significant improvements in balance and reduced fear of falling, with VR participants experiencing a 33% decrease in fall risk [14]. Overall, VR-focused research demonstrates improved rehabilitation outcomes. 

Should Virtual Reality Keep its Place in Healthcare?

Although the use of VR in rehabilitation has produced positive results, there are some limitations. The previously mentioned case studies are, unfortunately, limited in sample size, making it difficult to draw definitive conclusions. However, all the studies certainly show VR’s potential uses in rehabilitation. 

Neurorehabilitation aims to expedite recovery by leveraging the brain’s ability to adapt to stimuli and form new connections. The conclusions drawn from the case studies signify VR's ability to impact motor recovery and that utilizing immersive technology is the next step in the advancement of rehabilitation treatment. Healthcare professionals and rehabilitation therapists alike look to the future in hopes of seeing the advancement of post-stroke recovery. VR most certainly has a place in healthcare, and its position will only cement as research continues. 

References

1. Khokale, R., Mathew, G. S., Ahmed, S., Maheen, S., Fawad, M., Bandaru, P., Zerin, A., Nazir, Z., Khawaja, I., Sharif, I., Abdin, Z. U., & Akbar, A. (2023). Virtual and augmented reality in post-stroke rehabilitation: A narrative review. Cureus, 15(4), e37559. https://doi.org/10.7759/cureus.37559 

2. Center for Devices and Radiological Health. (2024, September 6). Augmented reality and virtual reality in medical devices. U.S. Food and Drug Administration. https://www.fda.gov/medical-devices/digital-health-center-excellence/augmented-reality-and-virtual-reality-medical-devices 

3. Laspro, M., Groysman, L., Verzella, A. N., Kimberly, L. L., & Flores, R. L. (2023). The use of virtual reality in surgical training: Implications for education, patient safety, and global health equity. Surgeries, 4(4), 635-546. https://doi.org/10.3390/surgeries4040061

4. Centers for Disease Control and Prevention. (2024, October 24). Stroke facts. Centers for Disease Control and Prevention. https://www.cdc.gov/stroke/data-research/facts-stats/index.html 

5. Dobkin, B. H. (2005). Rehabilitation after stroke. The New England Journal of Medicine, 352(16), 1677-1684. https://doi.org/10.1056/NEJMcp043511

6. Grefkes, C., & Fink, G. R. (2020). Recovery from stroke: Current concepts and future perspectives. Neurological Research and Practice, 2, 17. https://doi.org/10.1186/s42466-020-00060-6 

7. Barreto A. D. (2011). Intravenous thrombolytics for ischemic stroke. Neurotherapeutics : the Journal of the American Society for Experimental NeuroTherapeutics, 8(3), 388–399. https://doi.org/10.1007/s13311-011-0049-x 

8. Elendu, C., Amaechi, D. C., Elendu, T. C., Ibhiedu, J. O., Egbunu, E. O., Ndam, A. R., Ogala, F., Ologunde, T., Peterson, J. C., Boluwatife, A. I., Okongko, A. O., Fatoye, J. O., Akpovona, O. L., Onyekweli, S. O., Temitope, A. Y., Achimugu, A. O., & Temilade, A. V. (2023). Stroke and cognitive impairment: understanding the connection and managing symptoms. Annals of Medicine and Surgery (2012), 85(12), 6057–6066. https://doi.org/10.1097/MS9.0000000000001441 

9. Bateni, H., Carruthers, J., Mohan, R., & Pishva, S. (2024). Use of virtual reality in physical therapy as an intervention and diagnostic tool. Rehabilitation Research and Practice, 2024, 1122286. https://doi.org/10.1155/2024/1122286

10. Ostir, G. V., Berges, I.-M., Ottenbacher, M. E., Clow, A., & Ottenbacher, K. J. (2008). Associations between positive emotion and recovery of functional status following stroke. Psychosomatic Medicine, 70(4), 404-409. https://doi.org/10.1097/PSY.0b013e31816fd7d0

11. Grefkes, C., Fink, G.R. (2020). Recovery from stroke: Current concepts and future perspectives. Neurological Research and Practice. 2, 17. https://doi.org/10.1186/s42466-020-00060-6 

12. Drigas, A., & Sideraki, A. (2024). Brain neuroplasticity leveraging virtual reality and brain-computer interface technologies. Sensors, 24(17), 5725. https://doi.org/10.3390/s24175725 

13. Moan, M. E., Vonstad, El. K., Su, X., Vereijken, B., Solbjør, M., & Skjæret-Maroni, N. (2021). Experiences of stroke survivors and clinicians with a fully immersive virtual reality treadmill exergame for stroke rehabilitation: A qualitative pilot study. Frontiers in Aging Neuroscience, 13, 735251. https://doi.org/10.3389/fnagi.2021.735251 

14. Cortés-Pérez, I., Nieto-Escamez, F. A., & Obrero-Gaitán, E. (2020). Immersive virtual reality in stroke patients as a new approach for reducing postural disabilities and falls risk: A case series. Brain Sciences, 10(5), 296. https://doi.org/10.3390/brainsci10050296