articles

The last two decades demonstrated an exponential trend in the implementation of virtual reality (VR) in clinical settings [1]. Researchers and clinicians alike are enticed by the potential of this technology to enhance neuro- plasticity secondary to rehabilitation interventions. Cur- rently, Nintendo Wii, Sony PlayStation, and Microsoft Xbox offer commercially developed semi-immersive VR platforms which are used for rehabilitation [2]. Several studies report positive effects of these commercial tech- nologies for improving balance, coordination and strength [3–5]. In 2010, Microsoft introduced a novel in- frared camera that works on the Xbox platform called Kinect. The Kinect camera replaces hand held remote controls through the use of whole body motion capture technology.

Whole body motion capture VR allows a unique op- portunity for individuals to experience a heightened sense of realism during task-specific therapeutic activ- ities. However, clinicians need to be able to match a game’s components to an individual’s functional defi- cits. Seamon et al. [6] provided a clinical demonstration of how the Kinect platform can be used with Gentiles taxonomy for progressively challenging postural stability and influencing motor learning in a patient with pro- gressive supranuclear palsy. Similarly, Levac et al. [7] developed a clinical framework titled, “Kinecting with Clinicians” (KWiC) to broadly address implementation barriers. The KWiC resource describes mini-games from Kinect Adventures on the Xbox 360 in order to provide a comprehensive document for clinicians to reference. Clinicians can use KWiC to base game selec- tion and play on their client’s goals and the therapist’s plan of care for that individual.

In parallel with knowledge translation research, several studies found postural control improvements in multiple diagnostic groups including individuals with chronic stroke [8–10], Friedrich’s Ataxia [11], multiple sclerosis [12], Parkinson’s disease [13], and mild to moderate traumatic brain injury (TBI) [14] when using Kinect based rehabilitation. Additional research shows that ex- ercising with the Kinect system can reach an appropriate intensity for cardiovascular adaptation. For example, Neves et al. [15] and Salonini et al. [16] reported increases in ex- ercise heart rate and blood pressure in healthy individuals and children with cystic fibrosis while playing Kinect games. Similarly, Kafri et al. [17] reported the ability of in- dividuals post-stroke to reach levels of light to moderate intensity using Kinect games.

Individuals with TBI are likely to have a peak aerobic capacity 65–74% to that of healthy control subjects [18]. There is limited research on cardiovascular training after severe TBI [18]. However, Bateman et al. [19] demon- strated that individuals with severe TBI can improve

cardiovascular fitness during a 12-week program partici- pants exercised at an intensity equal to 60–80% of their maximum heart rate 3 days per week. Commercial Xbox Kinect games, such as Just Dance 3, have been shown to improve cardiovascular outcomes for individuals with chronic stroke [20]. However, there is a lack of research investigating the efficacy of motion capture VR on car- diovascular health for individuals with chronic severe TBI. Walker et al. [21] makes the recommendation for rehabilitation programs to go beyond independence in basic mobility and to develop treatment strategies to address high-level physical activities. The high rates of sedentary behavior in individuals across all severities of TBI could be attributed the lack of addressing these limitations in activity.

Postural instability is the second most frequent, self- reported limitation, 5 years post injury for individuals with severe TBI [22]. It is unknown whether use of mo- tion capture VR in individuals with severe, chronic TBI can address neuromotor impairments related to high- level activities such as maintaining postural control during walking. Similarly, there is a need to determine if training with VR motion capture can attain necessary intensity levels for inducing cardiovascular adaptation. Due to this knowledge gap and heterogencity of individ- uals post TBI, feasibility of investigatory interventions should be explored prior to examining effectiveness with randomized control trials. Single system experimental design (SSED) provides a higher level of rigor compared to case studies based on the ability to compare outcomes across phase conditions with the participant acting as their own control. The value of SSED within rehabilita- tion has been noted by other investigators [23, 24] mak- ing it an attractive design for practitioners aiming to gain insight into novel clinical interventions prior to large scale clinical trials. The purpose of this proof of concept and feasibility study was to evaluate the effect- iveness of commercially available Xbox One Kinect games as a treatment modality for the rehabilitation of balance and cardiovascular fitness for a veteran with chronic severe TBI. Additionally, we provide herein a description of the Kinect games to assist providers with clinical implementation.

Introduction (2)

The World Health Organization estimates that traumatic brain injury (TBI) is and will remain the most important cause of neurodisability in the coming years (1). The search for neuroprotective therapies for severe TBI has been extensive but unfruitful over the last few decades, testified by more than 30 failed clinical trials, and we still have no specific neuroprotective therapy, that is, effective in clinical TBI. The burden of mortality and residual disability calls for new approaches to promote recovery of function of TBI patients in the acute and chronic phase (2, 3).

Classically described as a sudden event with short-term consequences, TBI induces dynamic pathological cascades that may persist for months or years after injury with a major impact on outcome (4, 5). Among dynamic mechanisms, the neuroinflammatory response and the accumula- tion of aberrant proteins may have a critical role in establishing a neuropathological link between acute mechanical injury and late neurodegeneration (6, 7). The close association between post-TBI neurological changes, persistent neuroinflammation, and late neuropathology highlights the fact that the window of opportunity for therapeutic intervention may be much wider than previously thought and that long-term treatment encompassing the acute and chronic phase should be tested to effectively interfere with this complex condition.

Importantly, next to the harmful processes, TBI also induces a neuro-restorative response that includes angiogenesis, neurogenesis, and brain plasticity (8, 9). These spontaneous regenerative mechanisms are short-lived and too weak to counteract damage progression but they could point the way to new therapeutic options if appropriately boosted and amplified. Physical and cognitive exercise increase repair and brain plasticity after injury in experimental models and patients (10, 11). Rehabilitative programs to provide inputs/stimuli to specific sensory or motor neural circuits, could in principle start very early on, and be finely tuned over time to account for the type and degree of injury and the level of motor and cognitive disability.

Introduction (3)

Objective. Pediatric traumatic brain injury (TBI) is associated with physical and psychobehavioral impairment in children. Effective rehabilitation programs postinjury are critical for children with TBI. Virtual reality (VR) has been increasingly adopted for brain injury rehabilitation. However, scientific synthesis is lacking in evaluating its effectiveness in pediatric TBI rehabilitation. This article aimed to conduct a systematic review on the effectiveness of VR- based pediatric TBI rehabilitation. Methods. A systematic literature search was conducted in PubMed, PsycInfo, SCOPUS, CENTRAL, BioMed Central, CiNAHL, and Web of Science through November 2015. Personal libraries and relevant references supplemented the search. Two authors independently reviewed the abstracts and/or full text of 5824 articles. Data extraction and qualitative synthesis was conducted along with quantitative assessment of research quality by 2 authors. Results. A positive impact

was found for VR-based interventions on children’s physical rehabilitation post-TBI. The quality of research

evidence was moderate, which largely suffered from small samples, lack of immersive VR experience, and lack of focus on socioemotional outcomes post-TBI. Conclusions. The present review identified positive effects of

VR interventions for pediatric TBI rehabilitation especially in physical outcomes. Future research should include larger samples and broader

past few decades. TBI is caused by a bump, blow, or jolt to the head or a penetrating head injury, which disrupts the normal function of the brain.1 As a leading cause of acquired disability in children and youths in the United States, the Centers for Disease Control and Prevention estimated that 700000 children suffer from TBI every year, mostly from motor vehicle crashes or Pediatric TBI results in both short-term and long-term impairment in physical and psychosocial functioning. Physical deficits after pediatric TBI include changes in motor skills (eg, muscle tone, paralysis, balance, walking) and/or sensory abilities (eg, vision, hearing).5 The impact on children’s psychosocial abilities after pediatric TBI can be more enduring with potentially detrimental outcomes on cognitive, emotional, and interpersonal skills.6,7 One strategy to improve health outcomes among children with TBI is through postinjury rehabilitation interventions. These interventions include (a) physical rehabilitation focused on restoring a child’s strength, endurance, and motor flexibility and (b) cognitive rehabilitation comprising a broad collection of interventions that aim to improve psychosocial skills.8,9

Traditional physical and cognitive rehabilitation therapies are administered in-person by trained staff at hospitals, schools, communities, and/or homes. These therapies require significant amounts of costly medical personnel resources. Inaccessibility for some patients, especially those living in nonurban areas, or those without adequate medical insurance, leads to greater health disparities. To overcome such access barriers, modern technologies such as web-based/computer-assisted counseling programs and video games are increasingly being used to deliver rehabilitation interventions for children with TBI.10-12 Such preprogrammable interventions are more cost-effective because they can be remotely accessed and require significantly less medical staff resources, while still delivering training content that can be tailored to the specific needs of the child.

Virtual reality (VR), a rapidly developing field in computer technology, has drawn increasing attention in the pediatric health literature including TBI rehabilitation.13-15 According to the Merriam-Webster Dictionary, “virtual reality” is defined as “an artificial environment which is experienced through sensory stimuli (such as sights

and sounds) provided by a computer and in which one’s actions partially determine what happens in the environment.” This definition of VR, which has been widely adopted in the health literature,16-20 permitted the inclusion of both traditional video gaming consoles (eg, Wii, PlayStation, Xbox Kinetic) and the more cutting- edge VR technologies (eg, Oculus, HTC VIVE), as long as patients are able to experience live interactions with the gaming environment through sensory stimuli and/or motor feedback. In addition to offering the same flexibility, customizability, and accessibility as other computer-assisted interventions, VR-based rehabilitation can provide children with TBI at least the following 3 unique advantages over traditional paper-and-pencil and computerized interventions. First, VR interventions have the capability to offer a multitude of activities for training children with TBI following their injuries within a versatile virtual environment. Such environments offer interaction at all levels, from sensory and motor to cognitive and socioemotional, which greatly facilitate patients’ structural and functional recovery of their brains and are especially effective for children with TBI whose developing brains are highly plastic.16 Second, VR-based rehabilitation can be readily provided remotely by medical providers directly to patients’ home or nearby facilities either via the Internet or mobile apps, allowing postdischarge training sessions to be completed without requiring children to leave home. This could potentially reduce the long-term health outcome disparities especially for patient families who live in rural or remote areas. Last but not least, unlike traditional computerized rehabilitation training (especially in the domain of cognitive training), VR-based interventions may improve children’s adherence to training plans because of youth population’s increasing exposure to electronic games and the novelty of VR-based games.

Therefore, it is critical for both researchers and clinicians to gain a

big-picture understanding of the current practices and empirical evidence accumulated thus far regarding this emerging VR-based approach to pediatric TBI rehabilitation, for which purpose a systematic review on this topic would be appropriate. However, although existing syntheses on the effectiveness of VR-based interventions on TBI rehabilitation outcomes provided encouraging findings, they often failed to adopt a systematic review approach.16-18 Our literature search identified only one 2015 systematic review on the effectiveness of VR on TBI rehabilitation constrained to only adult patients with TBI,19 and one 2009 systematic review on VR application in acquired brain injury for upper limb rehabilitation.20 Hence, the objective of the present article is to conduct a systematic review on the effectiveness of VR-based interventions post-TBI children’s rehabilitation outcomes so as to further our understanding of the best practice for evidence-based rehabilitation for pediatric patients with TBI.

Introduction (4)

TRAUMATIC BRAIN INJURY (TBI) is one of the leading causes of mortality and morbidity worldwide,1 contributing to approximately 30% of all injury-related deaths2 in the United States. TBI severity can be divided into mild, moderate, and severe levels, depending on Glasgow Coma Scale score at presenta- tion, duration of posttraumatic amnesia, and neurologi- cal deficits.3 It is best understood as a pathophysiological

entity involving an acute injurious trigger for a chronic process manifesting (especially in moderate-severe TBI) as a multitude of deficits in sensorimotor, behavioral, and cognitive functions such as attention, memory, executive function, and problem-solving skills.4 , 5 This culminates in a considerable impact on everyday func- tioning and necessitates a multidisciplinary approach to an individualized rehabilitation program. Current ap- proaches are hindered by factors such as inadequate access to care centers and limited clinical resources.6 Furthermore, increasing survival rates due to advances in healthcare in this cohort corroborate the requirement for an adequate solution to this problem.7

The advent of virtual reality (VR) technology and its incorporation into rehabilitation approaches may provide an answer. Ellis8 defined VR as “interactive, virtual image displays enhanced by special processing and by non-visual display modalities . . . to convince users that they are immersed in a synthetic space.”(p17) Subsequently, rapid progress in technology means

that it is increasingly possible to “convince users that they are immersed” through various modalities such as head-mounted displays, 3-dimensional (3D) displays, joysticks, gloves, and haptic feedback from robotic arms. There is increasing evidence supporting the use of VR in cognitive rehabilitation in schizophrenia,9 depression,10 neurodegenerative disorders,11 and dementia.12 Essentially, VR technology is proving to be a valuable tool in the assessment, diagnosis, and treat- ment of chronic neurological and psychiatric disorders. It is well suited to this purpose for several reasons. (i) It provides a safe environment to practice activities of daily living (ADL); (ii) it offers the opportunity to tailor treatment modalities to the individual; and (iii) tasks can be subjectively entertaining,13 thereby circumventing issues associated with diminished moti- vation. The aim of this article is to provide a systematic review of the evidence available on effectiveness of VR technology in improving cognitive performance in patients with TBI and translation to real-life situations.

Introduction (5)

Motor vehicle crashes are the leading cause of death for vet- erans in their early years after returning from deployment and a top priority for the Department of Defense (DoD) and the Department of Veterans Affairs (VA), which is currently being addressed with an information campaign (www.safedriving. va.gov). This high collision rate could in part be due to more risk taking while driving1 and the high incidence of traumatic brain injury (TBI) both pre- and postdeployment.2

TBI can lead to significant cognitive, motor, perceptual, and behavioral deficits in an individual. Its impact varies widely between patients from “mild” (brief change in mental state or consciousness) to “severe” (an extended period of uncon- sciousness or amnesia following the injury) depending on the type of injury suffered. Recent reports suggest that 1.4 million Americans sustain a TBI each year, of whom 235,000 require hospitalization.3 According to estimates from the Centers for Disease Control and Prevention, at least 5.3 million TBI sur- vivors in the United States are dependent on their significant others to perform daily living activities.4 TBI is also one of the most frequent causes of acquired disability for people under the age of 35 in the United States.5 Although the major- ity of mishaps resulting in TBI in the civilian population are a result of falls and vehicular collisions,6 for active duty mili- tary personnel blasts are the leading causes of TBI (Defense

and Veterans Brain Injury Center, DoD, unpublished report, 2005). Over the last 9 years, the incidence rate of TBI-related hospitalizations was 22% higher during postdeployment com- pared to predeployment service.2

Driving is important for functional independence and psy- chological well-being of most adults. Driving a vehicle safely and proficiently has been referred to as the “ultimate multi- tasking” experience that requires synchronization of driver’s physical, cognitive, and behavioral skills.7 TBI, however, can seriously compromise an individual’s reaction time, hand-eye coordination, visual perception, memory, attention, and judg- ment. These impairments can result in poor driving perfor- mance, endangering not only the life of the TBI driver but lives of others on the road. According to a U.K. study, 64% of TBI patients who had reported driving before the injury had not resumed driving when inquired at a later time (3 months to 2 years after the head injury).8 Individuals recovering from a TBI who do resume driving, typically recognize their driv- ing difficulties, but do not make accommodations, e.g., avoid high traffic or night driving, and have 2.5 more collisions/ miles than the general population or drivers recovering from a stroke.9

High-quality and engaging driving rehabilitation techniques that focus on improving such driving impairments could has- ten and maximize recovery of driving skills in TBI patients. Given the extensive use of simulation in training military per- sonnel, it is surprising that simulation has not been applied routinely for purposes of driving rehabilitation in the military. In the past few years, the advantages of using virtual reality driving simulators to promote and facilitate better and safer driving in clinical populations have become more apparent.10 Simulation offers a safe environment for patients to practice and improve their impaired driving skills while being evaluated

objectively. However, in our review of the literature11 we found only one published study describing the use of virtual real- ity driving rehabilitation training with individuals recovering from a brain injury.12 This study reported impressive results as 73% of simulator-trained poststroke patients legally resumed driving (as per the official driving assessment) compared to only 42% of the controls ( p 0.05).

Here, we report a feasibility study investigating the pos- sible use of virtual reality driving simulation rehabilitation training with military personnel recovering from a TBI.

Introduction (6)

Approximately 1 million people in the UK sustain traumatic brain injury (TBI) each year and up to 150 000 incur moderate or severe injury [1] resulting in cognitive and psychological problems, such as impaired insight, executive dysfunction, anxiety and fatigue that interfere with activities of daily living including work [2].

The societal cost of TBI in terms of lost time at work and dependency on benefits is estimated to be 2.8 Billion Euros per year [3]. It is also a known cause of personal bankruptcy [4]. Those who don’t return to work are also more likely to be depressed [5].

Returning to work is a primary rehabilitation goal, yet reported success varies widely (range 11–82%) [6, 7]. In a systematic review, van Velzen et al. [8]

estimated that only a mean of 41% (range 0–85%) of TBI survivors who were working prior to their injury are in work at 1 and 2 years post-injury. Study heterogeneity and known difficulty in following TBI people up over time [8–10] explain some of the difference in reported outcomes, but ineffective rehabilitation cannot be excluded as a cause. Keeping TBI people in work is also problematic. Many TBI survivors return prematurely and drop out once the impact of the brain injury on their job is realized [11, 12].

Vocational Rehabilitation (VR), defined as what- ever helps someone with a health problem return to or remain in work [13], involves helping people find work, helping those who are in work but having difficulty and supporting career progression in spite of illness or disability [14, 15]. Clinical guidelines stipulate that VR should be provided [16] and keeping people with long-term conditions in work is a recognized health outcome [17, 18]. Despite this, UK services supporting TBI people in returning to work are rare [19, 20].

Whilst there is evidence to suggest the cost benefits of state-funded vocational rehabilitation models for TBI people (when programme delivery costs are offset against lost wages, lost income tax and public assistance [21–24]) most of these are retrospective analyses of clients undergoing rehabi- litation in a single centre and none make compar- isons to alternative or no provision. As such they fail to qualify as formal economic analyses and make it difficult to conclude that VR programmes are cost-effective in supporting return-to-work following TBI.

Positive work outcomes following vocational rehabilitation interventions have been reported in a number of studies. In a systematic review, Fadyl and McPherson [25] identified three broad approaches to TBI VR; programme-based; derived from the New York University Medical Center Head Trauma model [26], involving pre-employment training in vocational skills, sometimes supplemented by transi- tional job coaching and follow-up at set time points; supported employment [24, 27, 28] (where TBI people with minimal pre-placement training are placed in competitive employment with one-to-one job coach support for training and advocacy that decreases as job competence is established) and vocational case co-ordination, characterized by early hospital-based identification, modular VR interven- tion, employer education and workplace support. However, despite clear descriptions of the models themselves, a lack of high quality evaluations and dearth of RCTs with robust economic evaluations means evidence to support their effectiveness or cost-effectiveness is weak [29, 30]. The strongest evidence favours an individually-tailored, case-

coordination approach [31, 32] with early inter- vention to optimize employment outcomes [30, 31, 33–38].

The purpose of this pilot study was to determine whether a TBI specialist VR intervention (TBI VR) delivered by an occupational therapist as part of a specialist TBI team approach to care was more effective at supporting work return and retention 12 months after injury in people with TBI than usual care (UC) and to explore the feasibility of economic data collection and evaluation for a definitive trial.