Ten years ago, I read this influential paper in rehabilitation engineering that combined state-of-the-art technology into a very intensive protocol designed to promote recovery in individuals with chronic spinal cord injury1. The study combined conventional physiotherapy with brain-computer interfaces, haptics, exoskeletons, and immersive virtual reality. Despite the promising results, many readers (including myself) were left wondering: what were the main contributors to recovery?
My intuition at the time convinced me to look further at immersive VR for rehabilitation. I was lucky enough to collaborate with Henrique Balbino, a Master’s student at the University of Brasilia, and he developed an Unreal-based walking VR game for users with spinal cord injury. VR often generates a high sense of embodiment, which may be especially helpful for neurorehabilitation, and evaluating this was one of the goals in that project. The reaction from each participant with paraplegia was unforgettable: controlling a walking avatar in a game was certainly a type of game they wanted to play. Nevertheless, a combination of limitations on old VR systems and our design choices led to a more-than-recommended level of cybersickness. We were not there yet.
The next chapter in this story happened in Brisbane, at the University of Queensland. I was trying to pitch to clinicians projects based on complex electrical stimulation system when the COVID-19 pandemic happened, and all moved online. VR then became the best candidate technology for these collaborations, since we could develop a rehab tool at the lab and just send it to the hospital. It was also at that time that headset-based hand tracking became ubiquitous, enabling the intuitive use of your hand to interact with virtual environments. Immersive VR became easy to use for hand rehabilitation!
In Australia, I had the opportunity to supervise very talented students (Maia Coox, Bianca Zhang, Harshavardhan Bodla, Kate McNamara, and others) who were looking at: how can we facilitate the development of VR rehabilitation tools? This work, conducted alongside the Occupational Therapy Department at the Royal Brisbane and Women’s Hospital, resulted in a software library2 and games3 designed purposefully for therapy. One of the important outcomes regarded patient experience4. Different clinical populations tried our games, and the acceptance was fantastic, with very few reported issues. Feedback from patients and health professionals convinced us it is feasible to translate it into clinical practice.
Based on this experience, we also learned that, while commercial VR games are an engaging alternative to increase treatment dosage and intensity, VR apps designed specifically for rehab can deliver more. The games we designed enable controlling which body part or grasping should be trained, and quantitatively assessing patient performance. These early results encouraged us to look at: what other features we could manipulate to enhance rehab? And how do the corresponding mechanisms work? In Achintha Abayasiri’s PhD project, he applied realistic illusions in immersive VR and evaluated the effects on balance5 and walking, and Lucas Cardoso’s PhD included assessing sensorimotor integration and body representation when using VR6.
While these findings are exciting, we acknowledge that there are still multiple barriers for the use of immersive VR in rehabilitation. Alongside Kaitlyn Lake and Dan Kim, we have attempted to understand what are the cybersecurity implications of using VR systems in healthcare7, which is a major concern for clinicians and patients. In his PhD, Lucas also explored a different barrier: how to adapt readily available off-the-shelf VR applications for therapeutic purposes?
Back to that influential paper from around 10 years ago, I had the opportunity to meet in-person and separately with most of the authors in the study. And to all of them I asked the same question: what was the technology, the stimulus, that contributed more to recovery? Surprisingly (or not), each author picked a different one, being the brain-computer interface, the wearable haptics, the exoskeleton, or the immersive VR. But, they also stressed how essential is the integration of synchronised stimuli of different natures. Indeed, while in most of our published work in VR rehabilitation we offered an audiovisual experience only, we acknowledge that we need innovative VR hardware to increase the sense of embodiment and achieve the full potential of immersive VR in rehabilitation.
Here at OsloMet, I am leading an effort to establish a new VR-focused lab. With partners both here in Oslo and elsewhere, the goal is to create a space to accelerate the development of VR hardware and software and host pilot studies for applications in healthcare and other industries. If you’re interested, don’t hesitate to get in touch!
For now, a huge thank you to all my collaborators on this journey!