The Future of Virtual Reality in Neurorehabilitation: An Expert Roundtable

In the past 15 years, virtual reality (VR) technology has gained traction as a valuable tool in neurorehabilitation.1 In patients with multiple sclerosis (MS), for example, several studies published in 2023 demonstrated improvements in manual dexterity and upper limb motor function , as well as measures of daily functioning, quality of life, mood, and treatment satisfaction, following VR training.1-3

Additionally, in a 2022 meta-analysis published in the journal Neurological Sciences, researchers found that home-based VR training was associated with improvements in postural balance in patients with MS, Parkinson’s disease, and stroke.4

In a 2020 multicenter, single-blind randomized controlled trial published in Developmental Medicine & Child Neurology, the researchers compared the effects of a VR rehabilitation intervention combined with conventional occupational therapy to conventional therapy alone in children with cerebral palsy. The VR group showed greater improvements in upper-limb dexterity functions, activities of daily living, and forearm supination.5

Upon the completion of a 6-week home-based VR exercise program, some older adults with mild cognitive impairment reported physical benefits, and a few noted cognitive benefits, according to a 2020 study published in the Journal of Aging and Physical Activity. 6 The intervention was also shown to be safe and feasible, although no significant change in physical or cognitive outcome measures was observed.

In an ideal world, we would see high-quality clinical trials evaluating VR in all of these patient groups.

To learn more about the state of research and practice of VR technology in neurorehabilitation, we spoke with the following experts:

  • Hillel M. Finestone, MDCM, FRCPC, professor in the division of physical medicine and rehabilitation at the University of Ottawa and director of stroke rehabilitation research at Elisabeth Bruyere Hospital in Ontario, Canada
  • Lisa Sheehy, PhD, physiotherapist and research associate at the Bruyère Research Institute at the University of Ottawa
  • Sean Dukelow, PhD, professor in the department of clinical neuroscience at the University of Calgary in Alberta, Canada, and medical director of stroke rehabilitation for the Calgary Stroke Program

What are some positive ways that VR has transformed the neurorehabilitation space, especially in terms of patient engagement and commitment to treatment?

dr fine stone: In general, patients enjoy the ‘exer-gaming’ activities provided by VR technology. Some of them said it was less boring and that ‘the time goes quicker.’ Of course, the response depends on the game itself — some are very simplistic and can be perceived as ‘boring,’ but that is typically not the case.

dr Dukelow: I think of VR as a tool that we can use to gamify the rehabilitation experience, which can help with patient engagement. In a typical rehabilitation setting, VR can be used to augment things that a clinician might be working on with a patient. One of the exciting facets of VR is that it may be used to do things that are unique and difficult to pull off in a standard rehabilitation setting or a completely natural environment. One example might be trying to train a patient to scan for objects in an area where they have lost visual fields or have attentional impairment — this is something that can fairly easily be accomplished in VR.

Many patients really enjoy VR because of the game-based approach. It has a bit of an addictive side to it — consider the amount of people who loved to play games like Tetris and Candy Crush in the past. Certainly, we now have a whole generation of people who grew up with video games coming through the health care system, so the idea of ​​doing some of the rehabilitation by playing a VR game isn’t so foreign.

What are the differences and potential barriers in getting adults vs children to use VR in rehabilitation therapy?

dr Dukelow: I think one of the barriers to VR engagement has been the use of headsets in older adults, which could cause some problems with nausea. Traditionally, this has been dealt with by slightly less immersive VR systems — think big screens — but the newer headsets have higher refresh rates, so we are seeing less of those issues.

Can you discuss the neurobiologic mechanism that makes VR successful in neurorehabilitation?

dr Sheehy: Use of VR follows many of the principles of motor learning — that is, repetition, task-specific practice, meaningful practice, augmented feedback, observational learning, and motivation. There are studies that show enhanced neural activity in the affected brain due to participation in VR therapy.7

What makes VR use in neurorehabilitation such an intriguing option to clinicians?

dr Sheehy: VR can be implemented by therapists, rehabilitation assistants, family members, or volunteers. It can be used as a therapy modality or as an adjunctive therapy, or to provide extra rehabilitative exercise. It can be used for inpatients, outpatients, in the community, and in the home. It can be used for people with sub-acute and chronic conditions.

dr Dukelow: As I mentioned, VR is an intriguing option for clinicians because it can augment what they are doing in their 1-on-1 or group therapy sessions in the real world, and it can go beyond what the clinician is able to do in the real world. I’m not sure there is a well-established mechanistic explanation for why VR may be outperforming other therapies. Some have suggested that it has to do with increased engagement. We know that if a patient is more engaged and motivated, they are more likely to do their exercises.

In neurorehabilitation, how much you do matters, but most clinicians would argue what you do matters too.

Can you describe the evolution of VR-based interventions for physical and cognitive rehabilitation for various neurologic conditions?

dr Dukelow: In general, when a technology initially comes into neurorehabilitation, it often gets tested by an individual or group of people who have access to a certain patient population and think they might benefit from that technology. Over time, as the technology becomes more widely available, more and more people see it and think of its potential applications for other populations. You see a ‘creep’ or ‘spread’ in the indication.

This has happened for lots of different interventions in the neurorehabilitation space, from electrical stimulation, to robotics, to non-invasive brain stimulation. When a technology is non-invasive like VR, then it is very easy for clinicians to try it for different conditions. I think it’s important to state here that, at some point, the new technology needs to be properly tested in well-conducted clinical trials to see if it actually improves these conditions.

What are some conversations you’ve had with patients newly exposed to VR technology?

dr Sheehy: Most patients enjoy VR, and it inspires them to do more therapy. This also goes for patients who are older — even in their 90’s — or who have no previous experience with VR or with computers at all. Some who are very tech-adverse or too overwhelmed with their new reality are not interested. Those with a lot of gaming experience tended to find it dull and rather unpolished.

Patients prefer the games that are most intuitive and the most “gamified” — ie, the scoring system reflects success — and some participants in our research had the most difficulty with games that incorporated complex visuospatial tracking.6

dr Dukelow: Quite honestly, these are usually pretty short conversations. Of course, we have to walk through the potential risks and benefits of any treatment, but generally people are keen to try it out because the risks are minimal. Do we have people who aren’t interested? Sure, we have an occasional person who isn’t at all interested in video games or trying something tech-related, but most people want to give it a shot.

Which patient population do you believe will benefit the most from VR, and which population do you think should be the main focus of research in this area?

dr fine stone: I think VR-enhanced neurorehabilitation is a useful adjunct to traditional rehabilitation methods. I don’t think it can completely replace physiotherapists and occupational therapists. I do think that most neurorehabilitation patients would benefit from this technology. My vision for the future is that there will be specific games that target specific neurologic losses and disabilities.

For instance, a patient who has loss of balance due to a cerebellar infarct will be challenged with VR games targeting gait, sitting, and standing balance, and other similar activities. A patient with hemiparesis will play games targeting the weakened right arm and leg. There are currently specific exercise programs, particularly with physiotherapy, which are VR-based.

dr Dukelow: VR is a tool, and rehabilitation tools have the ability to cross different patient populations. With that lens, I think we are seeing that there are potential benefits for cognition, gait, and balance, and I think there exists considerable potential for motor recovery. You’ll notice these areas cross patient populations.

Would I like to see more efforts and funding put into stroke? Selfishly, as a stroke specialist, I would say yes, but I think there is significant potential in the other patient groups that you have brought up, and these patients also have tremendous needs for better interventions. In an ideal world, we would see high-quality clinical trials evaluating VR in all of these patient groups.

Editor’s Note: This interview was edited for clarity and length.

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