Virtual reality interventions facilitate rehabilitation through computer based, interactive, and multisensory experiences that occur in real time. Users are able to engage with simulated objects or events in a motivating and fun environment to develop a range of skills, movements or task-based techniques. Most importantly, virtual reality interventions meet the four guiding principles of rehabilitation: intensity, task-specific training, biofeedback and motivation (Dias et al. 2019). In addition, virtual reality based neuro-rehabilitation has been shown to engage the mirror-neuron system including the frontal, parietal and temporal lobes to encourage cortical reorganization and functional recovery (Kirshblum et al. 2004). In light of this, a variety of virtual intervention systems have been designed specifically for therapeutic use (e.g. Cyber Touch glove or Toyra) or developed using existing gaming consoles (e.g. Nintendo Wii). As technology becomes increasingly accessible and affordable, virtual reality interventions have the potential to improve upper extremity function and transfer therapy gains into activities of daily living for innumerable people. Despite this, few studies have investigated the use of virtual reality interventions for upper extremity rehabilitation following spinal cord injury.
The methodological details and results of these studies (n=6) are presented in Table 6.
In subacute and chronic stroke patients, improvements in upper limb function with virtual reality have been demonstrated; however, the evidence of its application in spinal cord injury is still very limited. The small number of studies presented here demonstrate that virtual reality interventions produce similar results to conventional therapy for upper limb function. A minority of studies, demonstrated significant improvement in aspects of hand function such as dexterity, coordination, and grip, as well as, specific activities of daily living. While the results of these studies are promising, they are rather preliminary. In this sense, virtual reality should not replace conventional therapy, however, it may be well suited as a supplement. The incorporation of virtual reality as a rehabilitation supplement has been shown to improve several motivating and social factors including perceived control, curiosity, exploration, imagination, cooperation, competition and social interaction (Lohse et al. 2013). Moreover, virtual reality may provide a more engaging treatment by allowing patients to interact with virtual objects in a variable environment selected by themselves (e.g. games, characters or levels). In turn, this may increase motivation and subsequently increase the dose of therapy received. However, as outlined by Prasad and colleagues, future research should focus on: (1) comparing virtual reality systems to conventional therapy with randomized controlled trials in a larger population, (2) development of telerehabilitation programs to compliment virtual reality intervention, and (3) efficacy of virtual reality systems and types of exercises included.
There is level 1b evidence (from two randomized controlled trials: Prasad et al. 2018, Dimbwadyo-Terrer et al. 2015) that virtual reality interventions (Nintendo Wii & Toyra) produce similar results to conventional therapy in upper limb function.
There is level 2 evidence (from one randomized controlled trial: Dimbwadyo-Terrer et al. 2013) that a virtual reality intervention (Toyra) significantly improves dexterity, coordination and grip functions in comparison to conventional therapy.
There is level 2 evidence (from one prospective controlled trial: Dimbwadyo et al. 2015) that a virtual reality intervention (Cyber Touch) produces similar results to conventional therapy and clinically improves dexterity, coordination and grip, although, not significantly.
There is level 4 evidence (from one pre-post test: Seanez-Gonzalez et al. 2016) that use of an interactive body machine interface in patients with high level SCI improves upper-body movement ability and stimulates structural brain changes.
There is level 4 evidence (from one pre-post test: Dimbwadyo et al. 2015) that conventional therapy complimented with virtual reality training (Toyra) for activities of daily living significantly improves self-care scores and range of motion in tasks related to eating, upper body bathing and grooming.
There is level 4 evidence (from one post-test: Foldes et al. 2015) that patients with complete hand paralysis can learn to significantly modulate their sensorimotor rhythms using a virtual hand task over time.