Immersive Virtual Reality to Improve Outcomes in Veterans With Stroke: Protocol for a Single-Arm Pilot Study

Abstract

Background Over the last decade, virtual reality (VR) has emerged as a cutting-edge technology in stroke rehabilitation. VR is defined as a type of computer-user interface that implements real-time simulation of an activity or environment allowing user interaction via multiple sensory modalities. In a stroke population, VR interventions have been shown to enhance motor, cognitive, and psychological recovery when utilized as a rehabilitation adjunct. VR has also demonstrated noninferiority to usual care therapies for stroke rehabilitation. Objective The proposed pilot study aims to (1) determine the feasibility and tolerability of using a therapeutic VR platform in an inpatient comprehensive stroke rehabilitation program and (2) estimate the initial clinical efficacy (effect size) associated with the VR platform using apps for pain distraction and upper extremity exercise for poststroke neurologic recovery. Methods This study will be conducted in the Comprehensive Integrated Inpatient Rehabilitation Program at the James A Haley Veterans’ Hospital. Qualitative interviews will be conducted with 10 clinical staff members to assess the feasibility of the VR platform from the clinician perspective. A prospective within-subject pretest-posttest pilot design will be used to examine the tolerability of the VR platform and the clinical outcomes (ie, upper extremity neurologic recovery, hand dexterity, pain severity) in 10 veteran inpatients. A VR platform consisting of commercially available pain distraction and upper extremity apps will be available at the participants’ bedside for daily use during their inpatient stay (approximately 4-6 weeks). Clinician interviews will be analyzed using qualitative descriptive analysis. Cohen d effect sizes with corresponding 95% CIs will be calculated for upper extremity neurologic recovery, hand dexterity, and pain. The proportion of participants who achieve minimal clinically important difference after using the VR platform will be calculated for each clinical outcome. Results This study was selected for funding in August 2020. Institutional review board approval was received in October 2020. The project start date was December 2020. The United States Department has issued a moratorium on in-person research activities secondary to COVID-19. Data collection will commence once this moratorium is lifted. Conclusions Our next step is to conduct a large multi-site clinical trial that will incorporate the lessons learned from this pilot feasibility study to test the efficacy of a VR intervention in inpatient rehabilitation and transition to home environments. When VR is used in patients’ rooms, it serves to provide additional therapy and may reduce clinician burden. VR also presents an opportunity similar to home-based practice exercises. VR can be implemented in both clinical settings and people’s own homes, where engagement in ongoing self-management approaches is often most challenging. This unique experience offers the potential for seamless transition from inpatient rehabilitation to the home. International Registered Report Identifier (IRRID) PRR1-10.2196/26133

Virtual reality applications for rehabilitation of COVID‐19 patients: A systematic review

“…When using a virtual reality headset, the user feels more present and immersed in the virtual environment. 28 These findings were aligned with those of a prior research that employed immersive virtual reality for rehabilitation. This technique was utilized by Huang et al to enhance upper extremity motor function among stroke patients.…”

Feasibility and Efficacy of a Virtual Reality Game-Based Upper Extremity Motor Function Rehabilitation Therapy in Patients with Chronic Stroke: A Pilot Study

“…The involvement of the upper extremity (UE) appears in up to 85% of patients who survive a stroke, affecting their quality of life [ 2 ]. The recovery of the motor function of the UE is essential in the development of ADLs, but it is also the origin of the difficulty of their recovery, as many of these activities require the coordinated use of both hands [ 3 ].…”

“…In stroke patients (in acute, sub-acute and chronic phases), the benefits of VR are demonstrated when it is used as a complement to another intervention, and its results are not inferior to other therapies when used as the single treatment. It offers benefits such as: the opportunity to interact in virtual environments similar to reality, through multi-sensory integration (visual, auditory, tactile), greater patient motivation and participation, as well as being increasingly economical, thus popularizing its use [ 2 , 6 ]. Despite their increasing use, there is a lack of games specifically designed for stroke patients.…”

Immersive Virtual Reality: A Safe, Scalable, Non-opioid Analgesic for Military and Veteran Patients

“…VR can also be used to support recovery from chronic pain by augmenting the efficacy of already established psychotherapeutic approaches such as CBT, exposure therapy, Dialectical Behavioral Therapy (Linehan, 1993), Mindfulness Based Stress Reduction (Kabat-Zinn, 1985 and other mindfulness based therapies. Furthermore, VR has been shown to support rehabilitation in clinical settings and to encourage at-home treatment adherence (Tran et al, 2021). Moreover, VR is a useful platform to provide interactive pain neuroscience education (PNE) about perioperative pain and expected recovery (Louw et al, 2020).…”

“…A growing number of studies on the application of VR analgesia have replicated the VR analgesia results in burn patients and during a wide range of other painful medical procedures (Atzori et al, 2018a;Carrougher et al, 2009;Indovina et al, 2018;Garrett et al, 2014;Hoffman et al, 2011;Malloy and Ming, 2010;Morris et al, 2009;Hoffman et al, 2000a,b;Hoffman, 1998;Trost, 2021a). Furthermore, VR has been shown to support rehabilitation in clinical settings and to encourage at-home adjustive treatment adherence (Tran et al, 2021;Hoffman, Boe et al, 2020).…”