Development and evaluation of an immersive virtual reality-based exercise system for poststroke upper limb motor rehabilitation

Abstract

Background: Virtual reality (VR) is an emerging strategy to deliver poststroke therapeutic exercises and facilitate motor recovery, but evidence to support the use of immersive VR in this field is insufficient. Objectives: This research aimed to examine the efficacy, safety, and stroke patients’ perceptions of an immersive VR-based exercise system for poststroke upper limb motor rehabilitation. Methods: A system supporting shoulder, elbow, forearm, wrist, and reaching exercises was developed. A proof-of-concept randomized controlled trial was conducted to examine the efficacy and safety of the system. Fifty stroke patients were randomized to either use the system to perform upper limb exercises (intervention) or play commercial games for entertainment (control), with 35 minutes/day, six days/week for two weeks. Efficacy outcomes included upper limb motor function (as assessed by the Fugl-Meyer Assessment for Upper Extremity [FMA-UE]), range of motion (ROM), strength, hand dexterity (Box and Block Test), arm and hand motor ability (Wolf Motor Function Test), perceived upper limb motor function, and quality of life (EQ-5D-5L). Safety was indicated by VR-induced discomfort, pain, and muscle spasticity. Measurements were collected at baseline and 1- and 2-week follow-ups. Between-group differences in efficacy outcomes were analyzed using linear mixed models, with intention-to-treat and per-protocol analysis. Safety outcomes were descriptively reported. Moreover, a questionnaire with a 7-point Likert scale (ranging from 1 to 7, with higher values indicating more positive perceptions) and semi-structured interviews were conducted in the last follow-up assessment to assess patients’ perceptions of the system. The measurement items in the questionnaire were summarized using descriptive statistics, and data obtained from the semi-structured interviews were content analyzed. Results: Intention-to-treat analysis revealed that after two weeks: (1) both groups significantly improved in ROM of shoulder flexion and abduction, and perceived upper limb motor function, and (2) the control group significantly improved in quality of life. Per-protocol analysis showed that after two weeks: (1) the intervention group significantly improved in ROM of shoulder abduction compared with the control group; (2) the intervention group significantly improved in coordination/speed (FMA-UE) and ROM of shoulder flexion; (3) both groups significantly improved in perceived upper limb motor function; and (4) the control group significantly improved in quality of life. VR-induced discomfort was mild; no severe pain or considerably increased muscle spasticity was observed. Moreover, the intervention participants’ perceptions of the system were positive (mean ratings > 6). Content analysis identified six themes from 89 statements regarding positive perceptions of the system, including ease of use, usefulness, enjoyment, motivation, accessibility, and game design; and identified three themes from 18 statements regarding negative perceptions of the system, including VR devices limitations, discomfort, and boredom. Conclusions: This system offers promise for improving shoulder range of motion and was found to be safe to use. Moreover, the patients overall had positive perceptions of the system. This research demonstrates that this system is a potentially effective, safe, and acceptable approach for supporting poststroke upper limb exercises. These findings can serve as a basis for larger-scale studies on the application of immersive VR for poststroke motor rehabilitation.