virtual reality in the treatment of upper …...• virtual reality as a tool for delivering ptsd...

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.


CASE STUDY #1


• 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??


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


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


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


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”


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


IMPLEMENTING VR FOR TBI: WHO WHAT WHEREWHEN AND HOW

• Inpatient Rehab

•Outpatient Rehab

•Home/ Community


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



• 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



• 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


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


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


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


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 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


REFERENCES

• Edwards, J., Vess, J., Reger, G., Cernich, A. The Use of Virtual Reality in the Military’s Assessment of Service Members with Traumatic Brain Injury: Recent Developments and Emerging Opportunities. Applied Neuropsychology: Adult. 2014; 21: 220–230.

• Highland, K.B., Kruger, S.E., & Roy, M.J. If You Build It, They Will Come, But What Will Wounded Warriors Experience? Presence in the CAREN. Annual Review of Cybertherapy and Telemedicine. 2015. doi:10.3233/978-1-61499-595-1-23

• 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

severe TBI. Brain Injury. 2011; 25(3): 274-281. DOI: 10.3109/02699052.2010.551648• Levin, M.F., Weiss, P.L., & Keshner, E.A. Emergence of Virtual Reality as a Tool for Upper Limb Rehabilitation: Incorporation of Motor Control and Motor Learning Principles.

Physical Therapy. 2015; 95(3): 415-425.• Mumford, N., Duckworth, J., Thomas, P.R., Shum, D., Williams, G., & Wilson, P.H. Upper-limb virtual rehabilitation for traumatic brain injury: A preliminary within-group

evaluation of the elements system. Brain Injury. 2012; 26(2): 166-176. DOI:10.3109/02699052.2011.648706• Neistadt, M.E. The effects of different treatment activities on functional fine motor coordination in adults with brain injury. American Journal of Occupational Therapy. Oct

1994; 48(10): 877-82.• Park, W.D., Jang, S.W., Kim, Y.H., Kim, G.A., Son, W., & Kim, Y.S. A study on cyber sickness reduction by oculo-motor exercise performed immediately prior to viewing virtual

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;

29(2):124–127.• Simmons, C.D., Arthanat, S., Macri, V.J. Pilot study: Computer-based virtual anatomical interactivity for rehabilitation of individuals with chronic acquired brain injury. JRRD.

2014; 51(3): 377-390.• U.S. Department of Veteran Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Concussion-mild Traumatic Brain Injury Version 2.0.

The Management of Concussion-mild Traumatic Brain Injury Working Group; Revised February 2016.• Virtual Reality as a Tool for Delivering PTSD Exposure Therapy (Albert Rizzo, JoAnn Difede, Barbara O. Rothbaum, J. Martin Daughtry, Greg Reger), Chapter in Post-

Traumatic Stress Disorder: Future Directions in Prevention, Diagnosis, and Treatment, Springer, 2013. • Wheeler, S., & Acord-Vira, A. (2016). Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda, MD: AOTA Press, The American

Occupational Therapy Association.• Wheeler, S., Acord-Vira, A., Arbesman, M., & Lieberman, D. Evidence Connection—Occupational therapy interventions for adults with traumatic brain injury. American

Journal of Occupational Therapy. 2017; 71(3): 7103395010p1-p3. https://doi.org/10.5014/ajot.2017.713005• Yunger, D. & Craelius, W. Improving Fine Motor Function After Brain Injury Using Gesture Recognition Biofeedback. Disabil Rehabil Assist Technol. Nov 2012; 7(6): 464-8.


virtual reality in the treatment of upper …...• virtual reality as a tool for delivering ptsd...

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