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VIRTUAL REALITY IN THE TREATMENT OF UPPER EXTREMITY FUNCTION IN ACUTE TBI REHABILITATION
CREATED BY BEN BARRETT, MOT, OTR/L, ATP, DAVE LAWLER, MA, OTR/L, CDRS &
LINDSAY MARTH, MA, OTR/L, BCPR
OF THE MINNEAPOLIS VA HEALTH CARE SYSTEM, OCCUPATIONAL THERAPY
OBJECTIVES
• Identify the standard of occupational therapy in TBI rehabilitation.
• Outline potential benefits of immersive virtual reality (VR) in TBI rehabilitation.
• Provide lessons learned and observations obtained to date of VR use in TBI
rehabilitation.
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
VR INTRO
• Video
Soundboxing (Maxint LLC) – Player punches orbs that
line up with the beat of a song.
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
CASE STUDY #1
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
• OT looks at the “job of living”- whatever the person
wants or needs to do in a day
• Self-care tasks, chores or yardwork, childcare
• Work or volunteer
• Hobbies and social activities
• Health changes can also impact mood, sleep, energy, and
cognition which also effects daily functioning
OCCUPATIONAL THERAPY- WHAT IS IT??
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
TRAUMATIC BRAIN INJURY DEMOGRAPHICS(EDWARDS 2014; US DEPT OF VA/DOD 2016; SALISBURY, 2016; SIMMONS, 2016)
• US
• 1.7 – 2.2 million incidence per year
• Risk factors include cardiovascular disease, falls which increase with aging population
• Military/ Veterans
• Between 2000-2012 over 4% of service members sustained a documented TBI
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
OCCUPATIONAL THERAPY FOR TBI ADDRESSES(WHEELER, 2016; WHEELER, 2017)
• Arousal, motor function, cognition, visual perception
• Psychosocial and emotional factors
• Social participation
•Occupational participation: ADL, IADL, work, community
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
OT FOR TBI CAN INCLUDE(SIMMONS, 2014; WHEELER, 2017; NEISTADT, 1994; YUNGER, 2012)
• Exercise programs
• Computer-based tools/Assistive Technology
• Postural and dynamic balance
• Multidisciplinary rehabilitation programs
• Constraint induced movement therapy (CIMT)
• Functional and table top activities
• Biofeedback
• Motor imagery, mirror therapy, mental rehearsalVR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
BOTTOM UP AND TOP DOWN STRATEGIES
Return to Work
Driving
Visual processing
Divided attention; Executive processing
UE Function
Computer Tasks
Sustained Focus
Social Interaction
Emotional Regulation
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
VIRTUAL REALITY AS A REHAB TOOL FOR TBI(EDWARDS, 2014; SALISBURY, 2016; SIMMONS, 2014; LARSON, 2011; MUMFORD, 2012; LEVIN, 2015; WHEELER, 2016; WHEELER, 2017; RIZZO, 2013; HOFFMAN, 2011)
• Fairly well tolerated and potentially effective tool to add to
conventional care to address cognition, ADLs, driving, fitness to return to
military duty
• Benefits
• Improved individualization and grading
• Application to real-world, meaningful tasks
• Optimizes neuroplasticity
• May increase motivation and focused attention to increase repetition
• Can serve as an effective distraction from painVR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
2-DIMENSIONAL VS HEAD MOUNTED DISPLAY(MUMFORD, 2012; LEVIN, 2015; HIGHLAND, 2015; EDWARDS, 2014)
• Benefits of HMD
• More immersive
• Reduced external distraction
• Embodiment
• Benefits of 2D
• Cost and accessibility
• More research completed
• Unknowns
• Do they have the same potential side-effects/ tolerance e.g. “simulator sickness”
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
IMPLEMENTING VR FOR TBI: WHO WHAT WHEN AND HOW
• Wide range of use across
• Age, gender, and cultural factors
• Physical function (e.g. option to adapt with straps or alternate sensors)
• Cognitive factors (e.g. able to follow 2 step directive)
• Potential Contraindications
• Occurrence of seizure
• Unstable mental health condition
• Visual impairments prohibiting use
• Communicable diseases preventing sharing of device
• Impulsivity preventing safe use VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
IMPLEMENTING VR FOR TBI: WHO WHAT WHERE WHEN AND HOW
• 2-D options
• Commercial devices such as Nintendo Wii, Microsoft Kinect
• Rehab devices that interface with 2D VR platforms
• Head Mounted
• Commercial devices such as HTC, Oculus, Windows Mixed
Reality, Smartphone-based
• New devices being released regularly
• Rehab-specific and commercial software
Nintendo Wii
HTC Vive Pro
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
IMPLEMENTING VR FOR TBI: WHO WHAT WHEREWHEN AND HOW
• Inpatient Rehab
•Outpatient Rehab
•Home/ Community
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
IMPLEMENTING VR FOR TBI: WHO WHAT WHERE WHEN AND HOW (SALISBURY, 2016; KENNEDY, 1993; PARK, 2017)
• Part of coordinated care plan, in addition to rather than substitute for other evidence
based treatments
• Dosing is person dependent and tapered
• Start with introduction and check tolerance
• Slowly build up duration and intensity
• Tolerance
• Simulator Sickness Questionnaire:
• 16 items; rate symptoms as none, slight, moderate, or severe
• mSSQ: headache, sweating, nausea, blurred vision, and dizziness with eyes open
• Other factors: patient satisfaction, changing health status, identified treatment priorities
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
IMPLEMENTING VR FOR TBI: WHO WHAT WHERE WHEN AND HOW
• Safety
• Coordinate with your facility e.g. Infection control for HMD
• Start seated and progress to standing as indicated/ tolerated (BERG, mSSQ)
• Equipment
• Identify existing or feasible to obtain equipment
• Start by exploring with:
• Staff
• Optimal candidates
• Increasing complexity
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
IMPLEMENTING VR FOR TBI: WHO WHAT WHERE WHEN AND HOW
• Select Games by Considering:
• Physical demands: UE, LE, endurance
• Cognitive demands: divided attention, processing
• Sensory processing demands: vision, hearing
• Ability to adjust and adapt to meet patient needs and treatment priorities
• Patient preferences
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
EXAMPLES OF GAMES FOR TBI AND UE
Fruit Ninja VR (HalfBrick Studios
PTY LTD) – Fruit comes at player
from all angles and needs to
be sliced with swords before
hitting the ground.
Soundboxing (Maxint LLC) –
Player punches orbs that line
up with the beat of a song.
VR Diner Duo (WhirlyBird Games)
– Player combines ingredients
to match a customer’s
hamburger order. VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
CASE STUDY #2
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
UPCOMING RESEARCH: AN IDEA WAS BORN
• PICO, OT department evidence based practice workgroup
• Connected with facility resources: AT, MADE, leadership
• Learned of and applied for grant through MN Spinal Cord Injury and
Traumatic Brain Injury Annual Research Grant Program
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
UPCOMING RESEARCH: THE PLAN
• Compare the outcomes when HMD VR is used as a tool during OT sessions for
inpatients with acute TBI to conventional OT
• Measure Outcomes Using
• Action Research Arm Test (ARAT)
• Measures of UE/hand function e.g. strength, coordination
• Self-care performance
• Patient satisfaction and impressions
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
UPCOMING RESEARCH: THE FUTURE
• Use knowledge gained to identify clearer pathway to the use of VR
• Across the TBI continuum of care
• In home and tele-rehab settings
• To address other treatment components such as cognition, emotional regulation, pain
• Connected to multi-modal sensory experiences, biofeedback, and haptic feedback
• Simulated outings, home evals, work tasks, etc
• Assessments more applicable to real-life challenges
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
VR RESOURCES
• VRHealth.Institute – provides exercise equivalents, assigns games ratings
based on observed MET score (a standard measure of exertion)
• VirtualMedicine.health
• UploadVR.com, RoadToVR.com – for information on VR products and software
VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH
REFERENCES
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• Hoffman, H.G., Chambers, G.T., Meyer, W.J., Araceneaux, L.L., Russell, W.J., Seibel, E.J., Richards, T.L. and Sharar, S.R. Virtual Reality as an Adjunctive Non-pharmacologic Analgesic for Acute Burn Pain during Medical Procedures, Annals of Behavioral Medicine. 2011; 41(2): 183S191.
• Kennedy R. S., Lane N. E. Simulator sickness questionnaire. Aviation Psychology. 1993; 3: 203-220. • Larson, E.B., Ramaiya, M., Zollman, F.S., Pacini,S., Hsu, N., Patton, J.L., & Dvorkin, A.Y. Tolerance of a virtual reality intervention for attention remediation in persons with
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reality (VR) content on head mounted display (HMD). Vibroengineering Procedia. Oct 2017; 14: 260-264.• Salisbury, D.B., Dahdah, M., Driver, S., Parsons, T.D., & Richter, K.M. Virtual reality and brain computer interface in neurorehabilitation. Proc (Bayl Univ Med Cent). 2016;
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VR IN TBI FOR BIA CONF 2019- BARRETT, LAWLER, & MARTH