Immersive Virtual Environments and Wearable Haptic Devices in rehabilitation of children with neuromotor impairments: a single-blind randomized controlled crossover pilot study

Abstract

Background: The past decade has seen the emergence of rehabilitation treatments using virtual reality. One of the advantages in using this technology is the potential to create positive motivation, by means of engaging environments and tasks shaped in the form of serious games. The aim of this study is to determine the efficacy of immersive Virtual Environments and weaRable hAptic devices (VERA) for rehabilitation of upper limb in children with Cerebral Palsy (CP) and Developmental Dyspraxia (DD).

Methods: A two period cross-over design was adopted for determining the differences between the proposed therapy and a conventional treatment. Eight children were randomized into two groups: one group received the VERA treatment in the first period and the manual therapy in the second period, and viceversa for the other group. Children were assessed at the beginning and the end of each period through both the Nine Hole Peg Test (9-HPT, primary outcome) and Kinesiological Measurements obtained during the performing of similar tasks in a real setting scenario (secondary outcomes).

Results: All subjects, not depending from which group they come from, significantly improved in both the performance of the 9-HPT and in the parameters of the kinesiological measurements (movement error and smoothness). No statistically significant differences have been found between the two groups.

Conclusions: These findings suggest that immersive VE and wearable haptic devices is a viable alternative to conventional therapy for improving upper extremity function in children with neuromotor impairments. Trial registration ClinicalTrials, NCT03353623. Registered 27 November 2017-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03353623.

Keywords: Human Motion Analysis; Rehabilitation; Serious game; Tactile Feedback; Virtual reality.

Fig. 1

CONSORT flow diagram. CONSORT flow diagram illustrating participant flow during the different phases of the study. Flow of participants, withdrawals, and inclusion in analysis are described [45]

Fig. 2

Set up illustration. a Screenshot of one of the experimental rehabilitation session with the VERA system. b, c Show detail of the fingertip haptic device rendering tangential and normal contact forces through cutaneous feedback [23, 46]. Screenshots of the virtual gaming scenarios [1, 2, 39] involving grasping and reaching task in the frontal plane (d), and path tracking tasks in the horizontal plane (e)

Fig. 3

Layout of VERA Rehabilitation Therapy. Layout of the exercises proposed in the VERA treatment, involving planar tracking (a) and reach-to-grasp (b) motor tasks, and the layout of the similar tasks proposed in the kinesiological assessment (c, d respectively)

Fig. 4

Clinical Scale Results Top graphs: Performance for each subject in the four assessment points: T0, pre-treatment assessment of Period 1; T1, post-treatment assessment of Period 1; T2, pre-treatment assessment of Period 2; T3, post-treatment assessment of Period 2. Period 1, from T0 to T1; Wash out, from T1 to T2; Period 2, from T2 to T3. Each subject is indicated by a different symbol and the kind of treatment he/she underwent in each period is marked by the color of the line (yellow for VR and blue for C). Bottom graphs: Performance changes between post- and pre-treatment measurements ($\mathrm{\Delta }P$) averaged over subjects within each period ($\mathrm{\Delta }P1$ and $\mathrm{\Delta }P2$). In order to improve the readability of the graphs in such a way to have higher values for better performance, $\mathrm{\Delta }P$ was multiplied by minus one. Colors distinguish the two groups (experimental sequence). Statistical significances of the $\beta$ LME model parameters are marked through asterisks (see Eq. 1, ${\beta }_0$ intercept, ${\beta }_1$ period, ${\beta }_2$ treatment, ${\beta }_3$ baseline, ${\beta }_4$ period*treatment)

Fig. 5

Results of the weighted error metric. Top graphs: Performance for each subject in the four assessment points: T0, pre-treatment assessment of Period 1; T1, post-treatment assessment of Period 1; T2, pre-treatment assessment of Period 2; T3, post-treatment assessment of Period 2. Period 1, from T0 to T1; Wash out, from T1 to T2; Period 2, from T2 to T3. Each subject is indicated by a different symbol and the kind of treatment he/she underwent in each period is marked by the color of the line (yellow for VR and blue for C). Bottom graphs: Performance changes between post- and pre-treatment measurements ($\mathrm{\Delta }P$) averaged over subjects within each period ($\mathrm{\Delta }P1$ and $\mathrm{\Delta }P2$). In order to improve the readability of the graphs in such a way to have higher values for better performance, $\mathrm{\Delta }P$ was multiplied by minus one. Colors distinguish the two groups (experimental sequence). Statistical significances of the $\beta$ LME model parameters are marked through asterisks (see Eq. 1, ${\beta }_0$ intercept, ${\beta }_1$ period, ${\beta }_2$ treatment, ${\beta }_3$ baseline, ${\beta }_4$ period*treatment)

Fig. 6

Results of the smoothness metric. Top graphs: Performance for each subject in the four assessment points: T0, pre-treatment assessment of Period 1; T1, post-treatment assessment of Period 1; T2, pre-treatment assessment of Period 2; T3, post-treatment assessment of Period 2. Period 1, from T0 to T1; Wash out, from T1 to T2; Period 2, from T2 to T3. Each subject is indicated by a different symbol and the kind of treatment he/she underwent in each period is marked by the color of the line (yellow for VR and blue for C). Bottom graphs: Performance changes between post- and pre-treatment measurements ($\mathrm{\Delta }P$) averaged over subjects within each period ($\mathrm{\Delta }P1$ and $\mathrm{\Delta }P2$). In order to improve the readability of the graphs in such a way to have higher values for better performance, $\mathrm{\Delta }P$ was multiplied by minus one. Colors distinguish the two groups (experimental sequence). Statistical significances of the $\beta$ LME model parameters are marked through asterisks (see Eq. 1, ${\beta }_0$ intercept, ${\beta }_1$ period, ${\beta }_2$ treatment, ${\beta }_3$ baseline, ${\beta }_4$ period*treatment)