Immersive virtual reality enhanced reinforcement induced physical therapy (EVEREST)

Background: Motor impairment of the upper limb (UL) post-stroke is prevalent, adversely affecting patients' quality of life. Previous research has shown that constraint-induced movement therapy (CIMT) is effective in UL rehabilitation. However, CIMT's rigorous regimen may hinder patient adherence, potentially affecting treatment efficacy. Immersive virtual reality (IVR) is an innovative approach for stroke rehabilitation. It utilizes VR technology to create dynamic environments and modify avatars efficiently, offering a less exhausting alternative to CIMT. We propose an IVR-based therapeutic approach that integrates positive reinforcement components to enhance motor coordination, offering an alternative to CIMT. This study aimed to evaluate the effect of incorporating positive reinforcement components into IVR-enhanced physical therapy (PT) on motor coordination. Method: Eighteen stroke patients were randomly allocated to two groups: the intervention group (n = 10) received 30 +/- 10 min/day of IVR therapy with PT, while the control group (n = 8) received PT alone. PT sessions, lasting 40 +/- 10 min/day, were conducted on the ward in accordance with national guidelines. The mean number of sessions across all participants was 6.6, with a standard deviation of 2.98. Session frequency was tailored to individual hospital stays, adjusted due to pandemic-related early discharge protocols. For participants with stroke who received IVR (intervention group), the task involved reaching for 35 targets randomly distributed across seven different locations in the VR environment. The number of movement repetitions varied, depending on their ability to repeat the task and the length of stay in the stroke unit. The movement of the virtual image of the UL was reinforced by visual feedback to the participants, that is, the participants perceived their motor coordination as if their image of the UL was moving to a greater speed than the real UL monitored realtime while the participants were trying to reach a target. The primary outcome measure was investigated by the Fugl-Meyer assessment (FMA) scale for the affected UL, with secondary measures including a kinematic dataset (e.g., time to target) and a questionnaire assessing participant perception and achievement during therapy. Results: The IVR group exhibited significant improvements in FMA scores (P = 0.02) between the first and fifth session, signifying a substantial recovery of UL motor function, with the fifth session showing higher scores. The time to target in the last session reduced compared with that in the first session, suggesting motor learning and recovery (P = 0.03). The patients were highly engaged and motivated during the sessions because they felt like they were in charge of controlling the virtual image of their upper body. Conclusions: The results suggest that positive reinforcement within the IVR could encourage motor recovery of the affected hand and may facilitate the application of motor learning and neuroplasticity principles during neurological rehabilitation.