Positive Technology Journal

The analgesic effects of opioids and immersive virtual reality distraction: evidence from subjective and functional brain imaging assessments.

Anesth Analg. 2007 Dec;105(6):1776-83, table of contents

Authors: Hoffman HG, Richards TL, Van Oostrom T, Coda BA, Jensen MP, Blough DK, Sharar SR

BACKGROUND: Immersive virtual reality (VR) is a novel form of distraction analgesia, yet its effects on pain-related brain activity when used adjunctively with opioid analgesics are unknown. We used subjective pain ratings and functional magnetic resonance imaging to measure pain and pain-related brain activity in subjects receiving opioid and/or VR distraction. METHODS: Healthy subjects (n = 9) received thermal pain stimulation and were exposed to four intervention conditions in a within-subjects design: (a) control (no analgesia), (b) opioid administration [hydromorphone (4 ng/mL target plasma level)], (c) immersive VR distraction, and (d) combined opioid + VR. Outcomes included subjective pain reports (0-10 labeled graphic rating scales) and blood oxygen level-dependent assessments of brain activity in five specific, pain-related regions of interest. RESULTS: Opioid alone significantly reduced subjective pain unpleasantness ratings (P < 0.05) and significantly reduced pain-related brain activity in the insula (P < 0.05) and thalamus (P < 0.05). VR alone significantly reduced both worst pain (P < 0.01) and pain unpleasantness (P < 0.01) and significantly reduced pain-related brain activity in the insula (P < 0.05), thalamus (P < 0.05), and SS2 (P < 0.05). Combined opioid + VR reduced pain reports more effectively than did opioid alone on all subjective pain measures (P < 0.01). Patterns of pain-related blood oxygen level-dependent activity were consistent with subjective analgesic reports. CONCLUSIONS: These subjective pain reports and objective functional magnetic resonance imaging results demonstrate converging evidence for the analgesic efficacy of opioid administration alone and VR distraction alone. Furthermore, patterns of pain-related brain activity support the significant subjective analgesic effects of VR distraction when used as an adjunct to opioid analgesia. These results provide preliminary data to support the clinical use of multimodal (e.g., combined pharmacologic and nonpharmacologic) analgesic techniques.

 

Electrodes attached to the patient's scalp measure the brain's electrical signals, which are amplified and transmitted to a computer. Highly efficient algorithms analyze these signals using a self-learning technique. The software is capable of detecting changes in brain activity that take place even before a movement is carried out. It can recognize and distinguish between the patterns of signals that correspond to an intention to raise the left or right hand, and extract them from the pulses being fired by millions of other neurons in the brain. These neural signal patterns are then converted into control instructions for the computer. "The aim of the project is to help people with severe motor disabilities to carry out everyday tasks. The advantage of our technology is that it is capable of translating an intended action directly into instructions for the computer," says team leader Florin Popescu. The Brain2Robot project has been granted around 1.3 million euros in research funding under the EU's sixth Framework Programme (FP6). Its focus lies on developing medical applications, in particular control systems for prosthetics, personal robots and wheelchairs. The researchers have also developed a "thought-controlled typewriter", a communication device that enables severely paralyzed patients to pick out letters of the alphabet and write texts. The robot arm could be ready for commercialization in just a few years' time.

Press release:Brain2Robot

Project page:Brain2Robot

Motor learning and the use of videotape feedback after stroke.

Top Stroke Rehabil. 2007 Sep-Oct;14(5):28-36

Authors: Gilmore PE, Spaulding SJ

BACKGROUND: Efforts have been made to apply motor learning theories to the rehabilitation of individuals following stroke. Motor learning poststroke has not been well investigated in the literature. This research attempted to fill the gap regarding motor learning applied to practice. PURPOSE: This two-group research study attempted to determine the effectiveness of an experimental therapy combining videotape feedback with occupational therapy compared to only occupational therapy in learning the motor skill of donning socks and shoes after stroke. METHOD: Ten participants were randomly assigned to one of the two groups and all participants were videotaped during pretest and up to 10 treatment sessions aimed at donning socks and shoes. Only one group viewed their videotape replay. The acquisition of donning socks and shoes was measured using the socks and shoes subtests of the Klein-Bell Activities of Daily Living Scale and their scores on the Canadian Occupational Performance Measure. RESULTS: There was no significant difference between the two groups and both groups improved. However, the group that received videotape feedback thought they performed better and were more satisfied with their ability to don shoes, lending support for the use of videotape feedback poststroke to improve satisfaction with performance.

fMRI Analysis of Neural Mechanisms Underlying Rehabilitation in Virtual Reality: Activating Secondary Motor Areas.

Conf Proc IEEE Eng Med Biol Soc. 2006;1:3692-3695

Authors: August K, Lewis JA, Chandar G, Merians A, Biswal B, Adamovich S

A pilot functional MRI study on a control subject investigated the possibility of inducing increased neural activations in primary, as well as secondary motor areas through virtual reality-based exercises of the hand. These areas are known to be important in effective motor output in stroke patients with impaired corticospinal systems. We found increased activations in these brain areas during hand exercises in VR when compared to vision of non-anthropomorphic shapes. Further studies are needed to investigate the potential of virtual reality-based rehabilitation for tapping into the properties of the mirror neuron system to stimulate plasticity in sensorimotor areas.

An article recently appeared in Time magazine reports about Smart Ambience Therapy (SAT), a series of interactive technology programs designed by Horace Ho-Shing Ip to help children overcome the effects of abuse.

From the article:

Cue-exposure therapy to decrease alcohol craving in virtual environment.

Cyberpsychol Behav. 2007 Oct;10(5):617-23

Authors: Lee JH, Kwon H, Choi J, Yang BH

During abstinence from alcohol, craving is elicited by the cues and contexts previously associated with alcohol, which contribute to relapse. To prevent the craving and relapse experienced by alcoholics, cue-exposure therapy (CET) has been used to extinguish the association between alcohol and alcohol-related cues and contexts. This study applied CET, using a virtual reality (VR) system, to eight members of an Alcoholics Anonymous group for eight sessions. Cues and contexts most likely to elicit an urge to drink were selected through a preliminary survey in order to compose VR-CET scenarios: a glass, a bottle, food, and a bar were judged to be the most tempting for people in alcohol dependence and abstinence. Using these cues and contexts, a Japanese-style pub and a western bar were created. Each session was administered for 30 minutes by a psychiatrist and included an introduction, immersion, VR navigation, interviews about feelings, and self-report questionnaires about cravings. The eight sessions consisted of initial and closing sessions and person-, object-, and situation-focused sessions. As a result, a reduction in cue-elicited craving after VR-CET was reported. A mean score of 15.75 (SD = 10.91) on the Alcohol Urge Questionnaire in the first session decreased to 11.50 (SD = 5.76) in the final session. This study suggests that using virtual reality can enhance the effectiveness of CET.

Via Medgadget

Doctors at Sister Kenny Rehabilitation Institute at Abbott Northwestern Hospital are using the new Nintendo video game console to help stroke victims recover.

Video 

Use of Virtual Reality to Improve Upper-Extremity Control in Children With Cerebral Palsy: A Single-Subject Design.

Phys Ther. 2007 Sep 25;

Authors: Chen YP, Kang LJ, Chuang TY, Doong JL, Lee SJ, Tsai MW, Jeng SF, Sung WH

BACKGROUND AND PURPOSE:/b> Virtual reality (VR) creates an exercise environment in which the intensity of practice and positive feedback can be systematically manipulated in various contexts. The purpose of this study was to investigate the training effects of a VR intervention on reaching behaviors in children with cerebral palsy (CP). Participants Four children with spastic CP were recruited. Method A single-subject design (A-B with follow-up) was used. All children were evaluated with 3 baseline, 4 intervention, and 2 follow-up measures. A 4-week individualized VR training program (2 hours per week) with 2 VR systems was applied to all children. The outcome measures included 4 kinematic parameters (movement time, path length, peak velocity, and number of movement units) for mail-delivery activities in 3 directions (neutral, outward, and inward) and the Fine Motor Domain of the Peabody Developmental Motor Scales-Second Edition (PDMS-2). Visual inspection and the 2-standard-deviation-band method were used to compare the outcome measures. RESULTS: /b> Three children who had normal cognition showed improvements in some aspects of reaching kinematics, and 2 children's change scores on the PDMS-2 reached the minimal detectable change during the intervention. The improvements in kinematics were partially maintained during follow-up. DISCUSSION AND CONCLUSION:/b> A 4-week individualized VR training program appeared to improve the quality of reaching in children with CP, especially in children with normal cognition and good cooperation. The training effects were retained in some children after the intervention.

Design and control of RUPERT: a device for robotic upper extremity repetitive therapy.

IEEE Trans Neural Syst Rehabil Eng. 2007 Sep;15(3):336-46

Authors: Sugar TG, He J, Koeneman EJ, Koeneman JB, Herman R, Huang H, Schultz RS, Herring DE, Wanberg J, Balasubramanian S, Swenson P, Ward JA

The structural design, control system, and integrated biofeedback for a wearable exoskeletal robot for upper extremity stroke rehabilitation are presented. Assisted with clinical evaluation, designers, engineers, and scientists have built a device for robotic assisted upper extremity repetitive therapy (RUPERT). Intense, repetitive physical rehabilitation has been shown to be beneficial overcoming upper extremity deficits, but the therapy is labor intensive and expensive and difficult to evaluate quantitatively and objectively. The RUPERT is developed to provide a low cost, safe and easy-to-use, robotic-device to assist the patient and therapist to achieve more systematic therapy at home or in the clinic. The RUPERT has four actuated degrees-of-freedom driven by compliant and safe pneumatic muscles (PMs) on the shoulder, elbow, and wrist. They are programmed to actuate the device to extend the arm and move the arm in 3-D space. It is very important to note that gravity is not compensated and the daily tasks are practiced in a natural setting. Because the device is wearable and lightweight to increase portability, it can be worn standing or sitting providing therapy tasks that better mimic activities of daily living. The sensors feed back position and force information for quantitative evaluation of task performance. The device can also provide real-time, objective assessment of functional improvement. We have tested the device on stroke survivors performing two critical activities of daily living (ADL): reaching out and self feeding. The future improvement of the device involves increased degrees-of-freedom and interactive control to adapt to a user's physical conditions.

Virtual Reality Applications in Improving Postural Control and Minimizing Falls.

Conf Proc IEEE Eng Med Biol Soc. 2006;1(1):2694-2697

Authors: McConville KV, Virk S

Maintaining balance under all conditions is an absolute requirement for humans. Orientation in space and balance maintenance requires inputs from the vestibular, the visual, the proprioceptive and the somatosensory systems. All the cues coming from these systems are integrated by the central nervous system (CNS) to employ different strategies for orientation and balance. How the CNS integrates all the inputs and makes cognitive decisions about balance strategies has been an area of interest for biomedical engineers for a long time. More interesting is the fact that in the absence of one or more cues, or when the input from one of the sensors is skewed, the CNS "adapts" to the new environment and gives less weight to the conflicting inputs [1]. The focus of this paper is a review of different strategies and models put forward by researchers to explain the integration of these sensory cues. Also, the paper compares the different approaches used by young and old adults in maintaining balance. Since with age the musculoskeletal, visual and vestibular system deteriorates, the older subjects have to compensate for these impaired sensory cues for postural stability. The paper also discusses the applications of virtual reality in rehabilitation programs not only for balance in the elderly but also in occupational falls. Virtual reality has profound applications in the field of balance rehabilitation and training because of its relatively low cost. Studies will be conducted to evaluate the effectiveness of virtual reality training in modifying the head and eye movement strategies, and determine the role of these responses in the maintenance of balance.

Virtual reality for the psychophysiological assessment of phobic fear: Responses during virtual tunnel driving.

Psychol Assess. 2007 Sep;19(3):340-6

Authors: Mühlberger A, Bülthoff HH, Wiedemann G, Pauli P

A new mechanical arm trainer to intensify the upper limb rehabilitation of severely affected patients after stroke: design, concept and first case series.

Eura Medicophys. 2007 Sep 10;

Authors: Hesse S, Schmidt H, Werner C, Rybski C, Puzich U, Bardeleben A

Description and case series on a new mechanical arm trainer with three degrees of freedom (DoF), the REHA-SLIDE (RS), for stroke rehabilitation are presented. Similar to a rolling pin, it consists of two handles at either side of a connecting rod, the handles are bilaterally moved forward and backward, sideways, and rotated, the base plate is inclinable. A computer mouse attached to the rod enables playing games offering computer-biofeedback. Two patients, 6 and 5 weeks after a first-time supratentorial stroke, suffering from a flaccid non-functional upper extremity have been studied. Interventions performed were additional 30 min of RS-training every workday for 6 weeks; one session included 400 repetitions evenly distributed between the forward backward movement and drawing a circle clock- and counter clockwise. Afterwards the patients could play games. Upper extremity portion of the Fugl-Meyer Motor Assessment Score (FM, 0-66), and muscle strength by a Medical Research Council (MRC) sum score (0-45), the FM assessment was blinded. In the 2 patients, the FM (0-66) improved from 7 to 37, and from 17 to 43, their initial (terminal) MRC sum scores were 6 (36) and 13 (31). With the REHA-Slide (RS), severely affected patients practiced a bilateral 3 DoF movement. No conclusions can be drawn so far and a controlled clinical study must be the next step.

The treatment of phantom limb pain using immersive virtual reality: Three case studies.

Disabil Rehabil. 2007 Sep 30;29(18):1465-9

Authors: Murray CD, Pettifer S, Howard T, Patchick EL, Caillette F, Kulkarni J, Bamford C

Purpose. This paper describes the design and implementation of a case study based investigation using immersive virtual reality as a treatment for phantom limb pain. Method. Three participants who experienced phantom limb pain (two with an upper-limb amputation, and one with a lower-limb amputation) took part in between 2 and 5 immersive virtual reality (IVR) sessions over a 3-week period. The movements of participants' anatomical limbs were transposed into the movements of a virtual limb, presented in the phenomenal space of their phantom limb. Results. Preliminary qualitative findings are reported here to assess proof of principle for this IVR equipment. All participants reported the transferal of sensations into the muscles and joints of the phantom limb, and all participants reported a decrease in phantom pain during at least one of the sessions. Conclusion. The authors suggest the need for further research using control trials.

Virtual-reality-Assisted treatment of flight phobia.

Isr J Psychiatry Relat Sci. 2007;44(1):29-32

Authors: Wallach HS, Bar-Zvi M

BACKGROUND: Flight phobia is a common and debilitating specific phobia. Recently, an effective technology, called Virtual Reality (VR), has been developed for the treatment of various anxiety disorders including flight phobia. METHOD: This article reports the results of a pilot study consisting of four subjects treated for Flight Phobia using Virtual Reality. RESULTS: All four subjects flew post-treatment. They experienced a significant reduction in fear of flying on two measures - anxiety about flying and global rating of fear of flying. Limitations: Due to the small sample size, the lack of a control group, and the lack of objective measures, caution must be exercised in interpreting the results. CONCLUSIONS: The use of Virtual Reality psychotherapy is relatively new worldwide, as well as in Israel. This study suggests the utility of implementing this technology in Israel.

Computer-Generated Virtual Reality to Control Pain and Anxiety in Pediatric and Adult Burn Patients During Wound Dressing Changes.

J Burn Care Res. 2007 Jul 20;Publish Ahead of Print

Authors: van Twillert B, Bremer M, Faber AW

Changing daily wound dressings provokes a substantial amount of pain in patients with severe burn wounds. Pharmacological analgesics alone often are inadequate to solve this problem. This study explored whether immersive virtual reality (VR) can reduce the procedural pain and anxiety during an entire wound care session and compared VR to the effects of standard care and other distraction methods. Nineteen inpatients ages 8 to 65 years (mean, 30 years) with a mean TBSA of 7.1% (range, 0.5-21.5%) were studied using a within-subject design. Within 1 week of admission, standard care (no distraction), VR, or another self-chosen distraction method was administered during the wound dressing change. Each patient received the normal analgesic regimen. Pain was measured with visual analog thermometer scores, and anxiety was measured with the state-version of the Spielberger State Trait Anxiety Inventory. VR distraction and television distraction both significantly reduced pain ratings compared with no distraction. Thirteen of 19 patients reported clinically meaningful (33% or greater) reductions in pain during VR distraction. No side effects were reported. There were no significant reductions in anxiety. No correlations were found between the reduction in pain ratings and patient variables like age, sex, duration of hospital stay, or percentage of (deep) burns. After comparing different distraction methods, only VR and television showed significant pain reductions during wound dressing changes. The effects of VR were superior, but not statistical significant, to that of television. There was no significant reduction of anxiety ratings.

Via Medgadget 

US company Myomo has announced that the e100 NeuroRobotic System, a technology designed to help in the rehabilitation process of patients by "engaging and reinforcing both neurological and motor pathways,"  has received FDA clearance to market.

How it Works

• Patient's brain is the controller: When a patient attempts movement during therapy, their muscles contract and electrical muscle activity signals fire
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• Non-invasive sensing: An EMG sensor sits on the skin's surface to detect and continuously monitor a person's residual electrical muscle activity
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• Proprietary system software: Advanced signal processing software filters and processes the user's EMG signal, and then forwards the data to a robotic device
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• Proportional assistance: Portable, wearable robotics use the person's EMG signal to assist with desired movement; power assistance is customized to patient ability with Myomo's real-time adjustable control unit.

Product page: Myomo e100 NeuroRobotic System ...

Via KurzweilAI

A humanoid robot designed to teach autistic children social skills has begun testing in British schools. Known as KASPAR (Kinesics and Synchronisation in Personal Assistant Robotics), the $4.33 million bot smiles, simulates surprise and sadness

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Virtual reality in stroke rehabilitation: Still more virtual than real.

Disabil Rehabil. 2007 Jul 30;29(14):1139-46

Authors: Crosbie JH, Lennon S, Basford JR, McDonough SM

Purpose. To assess the utility of virtual reality (VR) in stroke rehabilitation. Method. The Medline, Proquest, AMED, CINAHL, EMBASE and PsychInfo databases were electronically searched from inception/1980 to February 2005, using the Keywords: Virtual reality, rehabilitation, stroke, physiotherapy/physical therapy and hemiplegia. Articles that met the study's inclusion criteria were required to: (i) be published in an English language peer reviewed journal, (ii) involve the use of VR in a stroke rehabilitation setting; and (iii) report impairment and/or activity oriented outcome measures. Two assessors independently assessed each study's quality using the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) grading system. Results. Eleven papers met the inclusion criteria: Five addressed upper limb rehabilitation, three gait and balance, two cognitive interventions, and one both upper and lower limb rehabilitation. Three were judged to be AACPDM Level I/Weak, two Level III/Weak, three Level IV/Weak and three Level V quality of evidence. All articles involved before and after interventions; three randomized controlled trials obtained statistical significance, the remaining eight studies found VR-based therapy to be beneficial. None of the studies reported any significant adverse effects. Conclusion. VR is a potentially exciting and safe tool for stroke rehabilitation but its evidence base is too limited by design and power issues to permit a definitive assessment of its value. Thus, while the findings of this review are generally positive, the level of evidence is still weak to moderate, in terms of research quality. Further study in the form of rigorous controlled studies is warranted.

Virtual reality as a leisure activity for young adults with physical and intellectual disabilities.

Res Dev Disabil. 2007 Jun 20;

Authors: Yalon-Chamovitz S, Weiss PL

Participation in leisure activities is a fundamental human right and an important factor of quality of life. Adults with intellectual disabilities (ID) and physical disabilities often experience limited opportunities to participate in leisure activities, virtual reality (VR) technologies may serve to broaden their repertoire of accessible leisure activities. Although the use of VR in rehabilitation has grown over the past decade, few applications have been reported for people with ID. Thirty-three men and women with moderate ID and severe cerebral palsy participated in the study. Each participant in the experimental group (n=17) took part in VR activity two to three times weekly for 12 weeks. Virtual games were provided via GestureTek's Gesture Xtreme video capture VR system. The VR-based activities were perceived by the participants to be enjoyable and successful. Moreover, participants demonstrated clear preferences, initiation and learning. They performed consistently and maintained a high level of interest throughout the intervention period. VR appears to provide varied and motivating opportunities for leisure activities among young adults with intellectual and physical disabilities. Its ease of use and adaptability make it a feasible option for this population.