Top Banner
Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy Director, VEPO Lab Temple University State of the Science Symposia Series Virtual Reality Applications for Advancing Rehabilitation April 14, 2017
26

Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Jun 03, 2020

Download

Documents

dariahiddleston
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Balance Rehabilitation Through Virtual Environments

Dr. Emily A. Keshner

Professor and Chair, Department of Physical Therapy

Director, VEPO Lab

Temple University

State of the Science Symposia SeriesVirtual Reality Applications for Advancing Rehabilitation

April 14, 2017

Page 2: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Motivating

Activities that can be graded

to be demanding but

feasible

High intensity, repetitive exercise

Increased client

participation

Task-specific

practice

Varied, meaningful &

purposeful environmental

contexts

Significant Correspondence between key rehabilitation principles and Virtual Reality affordances (Levin, Weiss

& Keshner, 2015)

Client ‘s performance documented

Knowledge of performance &

results

Page 3: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Application of Virtual Reality to rehabilitation is becoming more common

Nintendo Wii is being used to work on weight bearing and increasing coordination, increasing strength and stability, increasing fine and gross motor skills.

Limitations: the parameters of the interaction are not well controlled:▪ how much force is produced?▪ is the whole limb or one joint being used?▪ can the game be tricked – are they really moving as we expect?▪ are the children learning anything beyond how to win the game?

Page 4: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Caution: “Active" video games don't necessarily boost physical activity

Accelerometer logs showed active games didn't promote any more exercise than inactive video games.

39 children chose from 5 active fitness-focused games and the other half from inactive games.

All received needed accessories including balance boards, remote controllers and resistance bands.

https://www.youtube.com/watch?v=HkMJIOzCTUE#!

Baranowski T et al, Pediatrics. 2012,129:e636-42

Page 5: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

What do we need in Clinical Interventions to Challenge Sensorimotor Integration?

• Matching experiences to patient deficits

• Grading complexity of sensory experiences

• Creating rich sensory environments for practice

Properties of Virtual Reality Environments

Page 6: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

•Trained for a 2 week period

•In the dark

•Increased sensitivity of platform each day up to 2 times COM motion

•Patient instructed to focus on position of hips and knees.

Balance Training on a Moving Platform in a VR CAVE

Haran and Keshner 2011

Page 7: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Postural Sway Decreases with Practice

• 73 yo female who falls • 10 years post-onset of bilateral

vestibular deficit • an active, community dweller • no other significant health problems

-20 -15 -10 -5 0 5 10 150

10

20

30

40

50COP Post-Training

Anterior-Posterior(cm)

Media

l-Late

ral(cm

)

COP 2 weeks Post-Training

Med

ial-

Late

ral (

cm)

Anterior-Posterior(cm)-20 150

0

50

Page 8: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Effect of Balance Training on Patients Post-Stroke

• Four adults with right

hemiparesis (39-67 years old)• At least 1-2 months post-

stroke • Berg Balance Scale scores

from 39-56• 5-20 deg reduction in ankle

range of motion in the paretic limb

• Lower limb vibration sense was intact

SUBJECTS

•Used visual motion and platform motion to produce instability

•Trained with plantar vibration in the dark to enhance stabilization

Page 9: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Thus, sensory integration training with VR can be used as a tool for modifying postural behavior

FORWARD

Reduced visual dependence and increased response regularity occurred following training

CO

P R

MS

(cm

)P

SD

of C

OP

(H

z)

Forward

Backward

Page 10: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Physiological Impact of Virtual Reality can be seen through psychophysical phenomena:

1. Immersion

2. Presence

3. Vection

4. Cybersickness

VR is not meant to replace real world action but to enhance it in order to

encourage CNS reorganization

Page 11: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

VR Immersion Promotes Verbal and Gestural Communication in Individuals with Aphasia

54

1

7

0

19

7

10

10

15

0

11

20

XH QH KC KG CM

Gesture Count per Participant

Pre-Gesture Gesture Post-Gesture

Set 1 Low High Low

Participant Hot Wok Capital Grille Owl Diner

XH46 .60 (n=45) .61 (n=67) .51 (n=41)

KC3 .38 (n=26) .36 (n=39) .27 (n=26)

CN39 .72 (n=25) .72 (n=32) .40 (n=25)

Set 2 Low High Low

Participant Florida Las Vegas Washington DC

XH46 .45 (n=65) .60 (n=72) .62 (n=50)

KC3 .33 (n=49) .43 (n=42) .43 (n=70)

CN39 .41 (n=41) .51 (n=35) .50 (n=32)

Table 2. Proportions of Utterances with Symbolic, Interactional, Referential

Pointing Gestures and Facial Experessions

Gesture Priming Condition and Dialogue ScenarioStory

Task

Page 12: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

S7

Random Dot Pattern

Left Right

Backward

Forward

S8

-3.5 -2.5 -1.5 -0.5 0.5

x-position (ft)

ankletrunkhead

-5

0

3

-5

0

3

S1

-3.5 -2.5 -1.5 -0.5 0.5

x-position (ft)

S3

Great Hall of Vection

Presence Modifies Motor Planning

Immersion NeuroPlasticity

Presence: To become unaware of your real surroundings and focus on your existence in the environment

Immersion: the feeling of beinginside and part of the virtual world

Page 13: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Immersion + Presence Promotes Adaptation to a Moving World

Participants:• 5 adults with unresolved dizziness (25-60 yrs)• chronic symptoms of dizziness and nausea • stood on dense foam while wearing an

Oculus Rift• 1-2x/week for 4 weeks • visual field was sinusoidally rotated at 0.25 Hz

for 60 sec, 3 times in each direction

Page 14: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Pre- and Post-training COP Footprints and Magnitudes

ROLL VISUAL SCENE PITCH VISUAL SCENE

POSTPRE POST

S3S2

ROLL VISUAL SCENE PITCH VISUAL SCENE

PRE

Pre-test

Post-test

Page 15: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Improved Sensorimotor Integration Improves Functional Balance

Pre-test

Post-test

During pre-testing, participants fell on 75% of the trials with visual scene motion – only one fall occurred during

post-testing!

Pre-test

Post-test

Page 16: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

IS IMPAIRED SENSORIMOTOR INTEGRATION LINKED TO FUNCTIONAL MOBILITY

visual

vestibular

somatosensory

Bleyenheuft (2013). Res Dev Disabil: 34, 3014-28.Horak and Macpherson (1996). Postural Orientation and Equilibrium.

• 90% individuals with CP have sensory impairments that alter sensorimotor integration

• Increased fatigue and pain

• Decreased locomotorfunction

• Decreased balance confidence

• Decreased quality of life

Page 17: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

23 Cerebral Palsy (CP)23 Typical Development

(TY)

32.3 ± 11.4 years 29.6 ± 11.0 years

SPASTIC CP- DIPLEGIC (n=16)- QUADRIPLEGIC (n=6)- HEMIPLEGIC (n=1)GMFCS: level I (n=15) & level II (n=16)

No known neurological disease

STAND INDEPENDENTLY at least 2 minutes at a time without assistance

STAND INDEPENDENTLY at least 2 minutes at a time without assistance

CORRECTED VISION 20/40 and better; no visual field deficits

CORRECTED VISION 20/40 and better; no visual field deficits

No botox injection in the past 3 months at the time of participation

PARTICIPANTS

Page 18: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Visual Dependence with CP(Rod and Frame Test)

TY

+

Visual

Independence

(TYVI) n=23

CP

+

Visual

Independence

(CPVI) n=10

CP

+

Visual

Dependence

(CPVD) n=13

Typical

Development

(TY) n=23

Cerebral

Palsy

(CP) n=23

Page 19: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

POSTURAL TASK in a Virtual Environment

5 s 30 s30 s

Sustained tilt at 3 degree

0 degree

Returning to 0 degree at

0.1 deg/sec

Quiet

Stance

Visual scene driven as:

1) Stationary

2) Eyes Closed3) Pitch Up 15°/s 4) Pitch Up 30°/s

5) Pitch Down15°/s6) Pitch Down 30°/s

No vestibular stimulation

COM with Fixed Base of Support

Page 20: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Balance is Sensitive to Visual Flow and Reflects Visual Sensitivity

Significant differences in COM to changes in visual flow by CPVD group suggests differences in stabilization of

the head and upper trunk.

Page 21: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Stabilized to space

Stabilized to inferior segment

Differences in COM are reflected in upper body response to visual field motion

Stabilized more to global space

(Head –

Thorax)(Thorax –

Hip)

(Hip – Ankle)

Isableu et al.(2003). Exp Brain Res 150:208-21.

θT

θH

Page 22: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

22

Head and Upper Trunk Response to Tilt (0-10 sec)

CP Visually Independent Trunk Motion

Typical Young Adult head and trunk stable

CP Visually Dependent head motion

Typical hold head and trunk stable in space

EO EC PU

PD PDPU

Eyes Open (EO) Eyes Closed (EC)

Pitch up Scene (PU)Pitch Down Scene (PD)

Page 23: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

CP Visually Independent

Typical Young Adult head motion

CP Visually Dependent

With diminished vestibular FB, Typical reorient with head motion;CPVD use the trunk more; CPVI lock head and trunk.

EO EC PU

PD PDPU

Head and Upper Trunk During Return from Tilt (30-60 sec)

Eyes Open (EO) Eyes Closed (EC)

Pitch up Scene (PU)Pitch Down Scene (PD)

Page 24: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

Summary• Specific sensory testing, spasticity, and strength did not differ

between the CP groups.

• Adults with CP and visual dependence exhibited greater sway in the direction of visual field motion particularly when somatosensory information was unreliable.

• Restricted mechanics with spastic CP requires a sensory reweighting that will modify stabilizing behaviors.

• VR is a more sensitive diagnostic tool than current measures of balance.

Page 25: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

What is the Clinical Value of VR?

• Intensity of effects can be modified to challenge the patients –e.g., direction and frequency of a visual field can be used to manipulate the size and timing of automatic motor responses

• Training engages users to allow for the repetitive intensive practice required for behavioral motor plasticity.

• Visual field motion adds cognitive demands to a task

• Can tailor interventions to address the particular needs of each patient

• Encourages motor learning through practice and repetition

• Provides environments to assess dynamic tasks that are performed everyday under controlled circumstances

• Adds sensitivity to functional clinical measures of disability.

Page 26: Balance Rehabilitation Through Virtual Environments · Balance Rehabilitation Through Virtual Environments Dr. Emily A. Keshner Professor and Chair, Department of Physical Therapy

• All authors have NO reported conflict of interest.

COLLABORATORS

Richard T. Lauer PhD

Yawen YuOT, PhD

Carole A. Tucker PT, PhD, PCS

Elizabeth D. Thompson PT, DPT, NCS

Irina ChudnovskayaBS

Sara Snell BS

Nadine MartinPhD