The current protocol outlines how the VR-based digital occupational training system enhances the rehabilitation of patients with cognitive impairment and upper limb dysfunction following a stroke.
Stroke rehabilitation often requires frequent and intensive therapy to improve functional recovery. Virtual reality (VR) technology has shown the potential to meet these demands by providing engaging and motivating therapy options. The digital occupational training system is a VR application that utilizes cutting-edge technologies, including multi-touch screens, virtual reality, and human-computer interaction, to offer diverse training techniques for advanced cognitive capacity and hand-eye coordination abilities. The objective of this study was to assess the effectiveness of this program in enhancing cognitive function and upper extremity rehabilitation in stroke patients. The training and assessment consist of five cognitive modules covering perception, attention, memory, logical reasoning, and calculation, along with hand-eye coordination training. This research indicates that after eight weeks of training, the digital occupational training system can significantly improve cognitive function, daily living skills, attention, and self-care abilities in stroke patients. This software can be employed as a time-saving and clinically effective rehabilitation aid to complement traditional one-on-one occupational therapy sessions. In summary, the digital occupational training system shows promise and offers potential financial benefits as a tool to support the functional recovery of stroke patients.
There is a high incidence, mortality, disability rate, and recurrence associated with stroke, or cerebrovascular accident1. Globally, stroke has surpassed tumors and heart disease to become the second leading cause of death, and it is the primary cause in China2. The incidence and social burden of stroke are expected to increase significantly in the coming years as the population ages. Survivors of stroke may continue to experience sensory, motor, cognitive, and psychological impairments3. The effects of a stroke can include paralysis of one side of the body, including the face, arms, and legs, a condition known as hemiplegia. This is the most common sequel to stroke and significantly impacts people’s quality of life4.
Stroke poses a significant threat to people’s health. Due to brain tissue damage, stroke and hemiplegia can result in hand dysfunction, hindering patients’ activities of daily living (ADLs) and diminishing their quality of life5. Decreased upper limb function, especially of the hands as the distal body part, presents the most significant challenge in upper limb recovery6. Therefore, functional rehabilitation is crucial. Additionally, 20%-80% of stroke patients experience cognitive impairment, leading to deficits in attention, memory, language, and executive abilities7.
Currently, the clinical rehabilitation of upper limb hemiplegia primarily relies on comprehensive upper limb training and various occupational therapies (e.g., mirror box treatment8, suspension9, functional electrical stimulation10, among others). Recently, virtual reality and interactive video games have emerged as alternative rehabilitation methods. These interventions can facilitate high-capacity practice and reduce demands on therapists’ time11. Virtual reality systems have rapidly evolved into new commercial devices that can be utilized to enhance cognitive and upper limb motor function in stroke survivors12. Despite these advancements, there are still unexplored avenues in this field.
Therefore, this study aims to investigate the effects of upper limb rehabilitation training combined with conventional upper limb rehabilitation on cognitive and upper limb motor function in stroke patients during the recovery period of hemiparesis, typically spanning the initial 6-24 weeks after the incident stroke. Additionally, we will examine its impact on daily life abilities. This research seeks to provide valuable evidence for the clinical application of robotic interventions.
This study protocol received approval from the ethics committee of the First Affiliated Hospital of Zhejiang University (approval number IIT20210035C-R2), and informed consent was obtained from all participants. An experimental study employing quasi-randomization, single-blinding, and a control group was conducted to assess the feasibility and effectiveness of the program. 24 patients hospitalized in the rehabilitation medicine ward of the First Affiliated Hospital of Zhejiang University were invited to participate in this experiment. Inclusion criteria encompassed stroke patients confirmed by computed tomography (CT) or magnetic resonance imaging (MRI), aged 30-75 years, 6-24 weeks post-stroke, a Montreal Cognitive Rating Scale (MoCA) score <2613, upper limb dysfunction14, unilateral hemiplegia, Brunnstrom stage 3-6 for sitting ability15, and cooperation for assessment and treatment. Exclusion criteria included a history of cognitive disorders, major organ dysfunction, visual or hearing impairment, abnormal mental behavior or antipsychotic drug use, severe spasticity (Ashworth scale 3-4)16, and shoulder subluxation or severe upper limb pain.
1. Study design
2. Training process of the digital occupational training system
NOTE: Only the experimental group receive these trainings.
3. Follow up procedures
In this study, 24 patients were enrolled presenting with upper limb dysfunction combined with various types of cognitive impairment following a stroke. The observed types of cognitive impairment included Amnesia, Agnosia, Executive Dysfunction, Attentional Impairments, among others. No statistically significant differences were found between the two groups in terms of sex, age, duration of disease, and type of stroke (P > 0.05), as detailed in Table 1. The experimental group, which underwent upper limb rehabilitation using the digital occupational training system, exhibited greater improvements in FMA-UE14, MoCA13, and MBI17 compared to conventional therapy (Table 2).
Following the training period, the experimental group demonstrated a significant improvement in MoCA scores (P < 0.05), while the control group did not show significant differences (P > 0.05). Moreover, the improvement in the experimental group was more pronounced than in the control group (P < 0.05) (Table 2). Regarding FMA upper limb scores, the experimental group showed significant improvement after 8 weeks of training (P < 0.05), with a notable difference in improvement compared to the control group (P < 0.05) (Table 2). Concerning BI scores, both groups exhibited significant improvements compared to before the intervention (P < 0.05), and the improvement in the experimental group was significantly different from that in the control group (P < 0.05) (Table 2). These findings underscore the effectiveness of the digital occupational training system in enhancing patients' cognitive and upper limb abilities, surpassing traditional rehabilitation therapy in cognitive improvements.
Statistical analyses were conducted using a statistical software (see Table of Materials), with the significance level set at a two-tailed P < 0.05. Parametric analysis, assuming data normality and homogeneity of variance, employed the independent samples t-test to compare differences between groups in scale scores.
Figure 1: Digital Occupational Training System. The system's screen is positioned at an ergonomically suitable height and angle for stroke patients in a seated or standing position, promoting interactive engagement for rehabilitation exercises. Please click here to view a larger version of this figure.
Figure 2: Game content and application of cognitive-based upper limb VR scheme. This figure graphically illustrates various tasks within the game, each meticulously designed to target specific cognitive and motor skills. Please click here to view a larger version of this figure.
Figure 3: Analysis of archery game training results – the number of rings per target hit. This figure provides a statistical breakdown of participants' performances within the archery game, visualizing the number of rings hit per target across multiple sessions. Please click here to view a larger version of this figure.
Figure 4: Analysis of archery game training results map of active areas. The color gradients represent areas of high and low activity, providing insight into the accuracy and focal points of participants' attempts, thus serving as a visual tool to assess motor control and coordination throughout the training. Please click here to view a larger version of this figure.
Group | n | Sex (n) | Age (x±s, y ) | Course of the disease (x±s, d) | Type of stroke (n) | Hemiplegic side (n) | |||||
Male | Female | Ischemic | Hemorrhagic | Left | Right | ||||||
Control group (n = 12) | 12 | 6 | 6 | 50.50 ± 5.50 | 37.08 ± 11.48 | 7 | 5 | 7 | 5 | ||
Experimental group (n = 12) | 12 | 7 | 5 | 50.42 ± 5.52 | 36.0 ± 10.86 | 8 | 4 | 6 | 6 | ||
P | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 |
Table 1. Baseline characteristics between the two groups. It presents a comprehensive comparison of baseline characteristics between the control and experimental groups. This includes demographic and clinical data, ensuring comparability between the groups and verifying the randomization process, hence confirming the robustness of the subsequent analysis.
Group | MoCA | FMA-UE | MBI | |
Control group (n = 12) | Per-treatment | 18.25 ± 2.42 | 31.83 ± 6.26 | 57.42 ± 7.37 |
Post-treatment | 19.0 ± 3.16 | 35.58 ± 5.04 | 64.33 ± 6.51 * | |
Experimental group (n = 12) | Per-treatment | 18.33 ± 2.34 | 32.42 ± 5.84 | 57.33 ± 9.50 |
Post-treatment | 22.00 ± 2.92 **# | 40.67 ± 6.72**# | 71.42 ± 9.63 **# | |
*P < 0.05, compared to pre-treatment; #P < 0.05, compared to the control group |
Table 2. Comparison of MoCA, FMA-UE, and MBI scores between two groups before and after training (x ± s). *P < 0.05, compared to pre-treatment. #P < 0.05, compared to the control group. The statistically significant values are highlighted, elucidating the impact of the VR-based training regime on cognitive and motor functions and showcasing the relevant improvements in participants' capabilities post-training.
A virtual reality rehabilitation system was implemented to support the recovery of stroke patients, utilizing the latest multi-touch screen technology to enhance training engagement, immersion, interactivity, and conceptualization. This system provides interactive upper limb motor control training that integrates vision, hearing, and touch. It also includes rehabilitation training modules targeting memory, attention, spatial perception, computing, hand-eye coordination, and virtual tasks, offering personalized cognitive training. Moreover, the digital rehabilitation enhances cognitive and upper limb recovery through enriched virtual activities of daily living (ADL) and cognitive training18,19.
The current approach to cognitive function rehabilitation post-stroke typically involves computer-assisted training and occupational therapy, sometimes supplemented by methods like hyperbaric oxygen therapy and transcranial electrical stimulation20. In contrast, the VR-based training system described here offers high-intensity, repetitive, and highly reproducible motor training21. The system intelligently adjusts game difficulty levels based on a patient’s rehabilitation progress, tailoring tasks for high-intensity training. Additionally, virtual reality games are accessible at any time and place, enabling patients to engage in rehabilitation training more frequently and achieve a higher number of repetitions.
Compared to existing VR devices, the digital occupational training system stands out as a more personalized and flexible rehabilitation option, concentrating patients’ efforts and attention for improved outcomes. Active participation by patients is crucial during neuroplasticity, motor learning, and rehabilitation. Combining rehab therapy with patients’ voluntary exercise has been found to promote the recovery of lost motor capabilities22,23. This virtual rehabilitation offers advantages in motivation, safety, and customization, while also allowing for the monitoring and analysis of users’ performance during training. Evaluations using a 7-point Likert-type scale have shown positive results, indicating improved acceptability, expectation effectiveness, satisfactoriness, and stability of the VR system24. Based on feedback from occupational therapists and individuals with cognitive impairment, the results suggest that this training system is both feasible and usable.
The virtual reality device can increase task repetitions (intensity) by enhancing enjoyment to encourage engagement in specific tasks. In comparison to existing VR devices, the digital occupational training system offers a more diverse range of cognitive and activities of daily living (ADL) training games. Low-cost virtual rehabilitation systems can serve as supplements to conventional rehabilitation, requiring reduced direct supervision. The utilization of motion sensors alongside VR systems allows rehabilitation professionals to digitally assess and track patients’ functions25. Rehabilitation based on a digital training system is a promising tool that enables patients to actively participate in rehabilitation plans and achieve better recovery of motor functions.
However, there are lingering questions, such as identifying the primary beneficiaries of virtual reality rehabilitation, assessing the impact of immersive vs. non-immersive experiences, and determining the most effective feedback mechanisms26. Virtual reality can also be integrated into new therapeutic modalities, such as brain-computer interfaces and noninvasive brain stimulation, to enhance neuroplasticity and improve recovery outcomes27. The study faced limitations, including challenges related to gesture recognition, the need for precise motion angle and timing adjustments based on patients’ motor capabilities, and the requirement for careful implementation of threshold limits6. Additionally, the relatively small sample size restricts the generalizability of the findings.
In conclusion, cognitive function training through a digital rehabilitation system significantly improves cognition, upper limb motor function, and ADL capabilities in stroke patients. This approach holds substantial potential for clinical rehabilitation and could be expanded to benefit more stroke rehabilitation centers in the future. Furthermore, the versatility of this method allows its application in various rehabilitation fields, including trauma recovery and the treatment of neurodegenerative diseases.
The authors have nothing to disclose.
We thank the patients and healthcare staff of the First Affiliated Hospital of Zhejiang University School of Medicine for their support and cooperation throughout this study.
FlexTable digital occupational training system | Guangzhou Zhanghe Intelligent Technology Co., Ltd. | Observation on the rehabilitation effect of digital OT cognitive function training on stroke patients with decreased attention function | FlexTable digital operation training system uses the latest multi-touch screen technology, virtual reality and human-computer interaction technology, integrates a variety of training methods, and provides digital advanced brain function and hand-eye coordination training |
SPSS 25.0 | IBM | https://www.ibm.com/support/pages/downloading-ibm-spss-statistics-25 |