Using VR Platforms to Improve Functional Outcomes After ABI

Each month at Ability Partners, our hard-working Occupational Therapists gather to present, analyse and discuss different journal articles. This journal article was sourced to support the review of current literature for the use of VR platforms that incorporate ADLs to improve functional outcomes after ABI.

Our OT’s covered the following journal about functional outcomes after ABI:

Grewal, J., Eng, J. J., Sakakibara, B. M., & Schmidt, J. (2024). The use of virtual reality for activities of daily living rehabilitation after brain injury: A scoping review. Australian Occupational Therapy Journal. https://doi.org/10.1111/1440-1630.12957

What is an Acquired Brain Injury (ABI)?

Acquired Brain Injury (ABI) refers to damage to the brain that occurs after birth and includes diseases such as stroke and traumatic brain injury (TBI). Annually, 13.1 million people experience moderate to severe TBI and 16.9 million experience a stroke making it a leading cause of disability worldwide.

Individuals with ABI face health and social outcomes as a result of their injury which leads to long-term physical and cognitive challenges.

Common issues with ABI include:

Poor mental health (depression, anxiety)
Difficulty with employment
Relationship problems

ABI also often results in impaired ADLs which affects recovery and quality of life. Rehabilitation needs to be tailored to individual goals and environments, but there are limited evidence-based interventions. OTs focus on ADLs, but guidelines and effectiveness vary across settings. Because of this, there is an urgent need for evidence-based ADL rehabilitation practices.

Virtual Reality (VR)

Virtual Reality (VR) creates simulated environments for users to interact with in a realistic way.

Types of VR platforms include:

Fully immersive (head-mounted displays)
Non-immersive (computer/video game consoles)
Semi-immersive systems

Advantages for Rehabilitation

VR enables safe practice of difficult tasks in a controlled environment, enhancing engagement and motivation.
Allows for customisable and individualised therapy by adjusting activity difficulty as users progress.
VR can improve the ecological validity of rehabilitation, closely simulating real-world activities and improve functional outcomes after ABI.

When a client understands the systems, they may be able to operate it independently, leading to the removal of a supervisor.

Evidence and Application

VR shows potential in improving mobility, motor learning and upper limb function after ABI. It’s used in home, inpatient, and outpatient settings through compliance varies.

Systematic reviews indicate VR’s effectiveness in improving cognitive and physical outcomes post-stroke and TBI.

Cognitive outcomes explained:

VR interventions can improve various cognitive functions including orientation, planning and organising, attention, problem-solving, social appropriateness, and communication skills (reading and writing).
These cognitive enhancements are achieved through engaging and interactive VR scenarios that simulate real-life tasks and challenges, requiring users to actively process information, make decisions and respond appropriately.

Physical outcomes explained:

VR can also enhance physical functions such as range of motion (ROM), coordination, balance and spatial awareness.
Through repetitive and targeted VR exercises, patients can practice and refine their motor skills in a controlled environment that provides immediate feedback and adjusts difficulty levels to match their progress.

Research is still evolving, with ongoing exploration needed to maximise VR’s rehabilitation potential.

Methodology Review

Using the Arksey and O’Malley (2005) framework:

Stage 1: Identifying the research question

PICO Framework

Population: ABI (stroke, TBI)
Intervention: VR with ADL activities
Outcome: Functional improvements
Question: Current literature and gaps in VR for ADL improvement in ABI

Stage 2: Identifying Relevant Studies

Databases: OVID, Medline, Embase, CINAHL, APA PsycINFO
Date: May 20, 2022
Search Terms: ABI, VR, ADLs

Stage 3: Study Selection

Inclusion and exclusion criteria below. Process: Screened by three reviewers, resolved conflicts with lead researcher.

Inclusion

Adults (18+), stroke or moderate/severe TBI
VR interventions with ADL tasks
Pre-post studies and RCTs.

Exclusion

Children, healthy participants, milt TBI.
Protocols, VR development, lower limb data, leisure/gaming tasks, home interventions
Case studies, qualitative studies, no full-text

Stages 4 + 5: Data extraction and reporting:

Checklist: TIDierR
Data points: study design, participants, VR protocols, ADLs, outcomes, results, adverse events, user experience
Focus: Changes in upper limb, cognitive, and ADL outcomes.

Main Findings

Study Selection Process

Conducted electronic database search yielding 1680 unique titles.
413 articles matched criteria after screening titles and abstracts.
After full-text screening, 12 articles were included, with one more added through key database searching, totalling 13 included articles.
All included articles were published after 2000, with 11 published in the last decade.
Study locations varied, with many in the United States and United Kingdom.

Study Designs

Six studies were randomised controlled trials (RCTs), and seven were pre-post intervention studies.
Among RCTs, two were smaller scale RCTs, and one was considered a pilot RCT.

Participants

Total participants across studies: 249 with stroke, 13 with moderate to severe TBI, two with encephalitis, and 20 healthy controls.
Age range of participants: 18 to 91 years.
Inclusion criteria varied but generally included participants with normal cognition capable of using VR equipment.

Intervention

Various VR platforms were used, including non-immersive, semi-immersive, and immersive setups.
Activities included ADL tasks like grocery shopping, meal preparation, and other daily tasks.
VR interventions were delivered in clinical or research settings by professionals.

Training Period and Control Groups

Session length varied from 20 minutes to 1 hour, with an average of 45 minutes per session.
Dose of intervention ranged from 2 to 4 sessions per week in most studies.
Control groups received various interventions, such as conventional therapy or non-ADL VR tasks.

Outcome Measures and Impact

Outcome measures included assessments of upper limb function, cognition, and ADL performance.
Mixed results were observed regarding the impact of VR on upper limb function, cognition, and ADL performance.
Some studies reported statistically significant improvements, while others did not show significant effects.

Adverse Events and User Experience

Six studies investigated user experience and adverse events, reporting generally positive feedback with minimal adverse effects.
VR interventions were generally well-received by participants, with good usability and acceptability reported in several studies.

Limitations

Non-English studies were excluded, potentially resulting in an incomplete synthesis of information
Rapid research developments and not including all sources may have led to missing relevant studies
Not including single case study designs might have affected the data on feasibility and novel VR designs
Studies were not characterised by stroke type, side, or severity due to the limited number of studies available
ADLs were strictly defined as consistent daily activities (e.g. preparing a meal, shopping, dressing)
Only pre-post intervention and RCT studies were included. RCTs have limitations with technology-based interventions, and pre-post designs can inflate effect sizes compared to studies with control groups.

Key Points for OT’s

Virtual reality (VR) is a novel occupational therapy treatment for acquired brain injury.
- VR is emerging as a cutting-edge intervention method for individuals with ABI, offering innovative ways to engage patients in therapeutic activities that mirror real life tasks and provide functional outcomes after ABI.
Generally, VR platforms have been shown to be safe and feasible to use with individuals with ABI.
- Studies indicate that both immersive and non-immersive VR platforms are generally safe for use with ABI patients, with minimal adverse effects such as nausea or disorientation. This makes VR a viable option for clinical settings.
Occupational therapists may use these findings to determine suitability of VR for ADL rehabilitation.
- Occupational therapists can leverage VR technology to simulate ADLs, such as grocery shopping, meal preparation, and other household tasks, allowing patients to practice and improve their cognitive and physical skills in a controlled, risk-free environment.
Specific Cognitive and Physical Outcomes addressed by VR:

Cognitive Outcomes:

Orientation: Helping patients improve their sense of time, place, and situation through interactive scenarios.
Planning and Organising: Engaging patients in activities that require step-by-step execution and sequencing.
Attention and Focus: Tasks designed to enhance sustained, selective, and divided attention.
Problem-Solving: Simulating real-world challenges that require critical thinking and decision-making.
Social Appropriateness: Scenarios that improve social skills and appropriate responses in various social settings.
Communication Skills: Activities that involve reading, writing, and verbal communication to strengthen these skills.

Physical Outcomes:

Range of Motion (ROM): Exercises that encourage movement in different joints and directions.
Coordination: Activities that improve hand-eye coordination and fine motor skills.
Balance: VR scenarios that require patients to maintain or adjust their balance.
Spatial Awareness: Tasks that enhance understanding and navigation of physical space.

Conclusion

Virtual Reality (VR) demonstrates considerable potential as an adjunct in occupational therapy for patients with Acquired Brain Injury (ABI).
Occupational therapists are advised to prioritise safety and feasibility assessments when contemplating the incorporation of VR interventions.
Future research endeavours should concentrate on comparative analyses of diverse VR platforms and the implementation of patient-centric care models.
The insights and perspectives of clinicians are pivotal for the effective integration of VR technologies into neurorehabilitation programs.
Occupational therapists assume a crucial role in the evaluation and customisation of VR interventions to ensure optimal clinical outcomes.

At Ability Partners, we work in partnership with you to achieve goals that really matter. We deliver evidence-based practice and work with you as a team. Contact Ability Partners today.