The role of virtual reality in vestibular rehabilitation

In this video, Dr Michelle Petrak will explore the exciting field of virtual reality and how this can be incorporated into rehabilitation programs, focusing on dual tasking, engagement, dosing and personalization. You can read the full transcript below.

Introduction

Hello everyone. I'm happy to be here speaking with you again, this time on cognition and motor training, with an emphasis on dual tasking in rehabilitation. And even more specifically, we're going to talk about how we can use different virtual reality strategies in our rehabilitation to accomplish this cognitive and motor training in dual tasking.

What is dual tasking?

So what exactly is a dual task? It is as simple as it sounds. It just means doing two things at one time. But this is really important for doctors and therapists because they want to assess the patient's motor skills while they're completing a cognitive task.

And that's because this brings out deficiencies that we may not see when the patient is doing a single task. And this is very common in patients that have concussion and neurodegenerative disorders that we really want to incorporate this dual tasking to dig out some of those deficiencies. And again, we might not see with a simple or a single task.

So let me give you a quick example of what a dual task might be. So in the tug test, the time up and go test, the patient was asked to stand up, walk ten feet through and walk back and sit down. If we wanted to turn that simple single task into a dual task, then we could just ask the patient once to do the same thing, get up, walk ten feet, turn around and come back.

At this time, I want you to count backwards by three, starting from 100. So 100, 97, 94, 91. And then we time them and well, notice that the extra cognitive task makes it much more challenging for them to do the activity.

Cognitive tasking

So we know that cognitive tasking is challenging and we know that when we add a cognitive task for mobility, a gait or a balance task, that I can increase the gait variability, especially of patients, neurological disorders, lots of literature that shows us that we know that Parkinson's disease, multiple sclerosis, we know that in these cases and it can increase postural sway, it can increase variability in stride time.

So any impairment or challenge that affects attention may prevent an individual from being able to allocate appropriate resources to be able to keep their balance in their gait. Difficult situations like walking an uneven pavement. And this can lead to a fall. And we know that falls are not what we want to see in our patients. They oftentimes have very long-term negative effects.

Dual tasking in everyday living

We do dual tasking in our everyday living situations. We don't even realize it, right? Dual tasking is walking through a crowd and talking on your phone. The difficulty here for the physical therapist or the person that is going to be doing the rehabilitation of the patient is they can't really take them out on the street, put them on the telephone and start doing exercises with them.

Right. So that's where virtual reality comes in. Virtual reality allows us to create these scenes like being in a crowded situation, but in the comfort, convenience and safety of our clinics so we can put a headset on and stop that patient in a crowded scene while doing some tasks with them.

We could do cognitive tasks; we could do motor tasks while they're inside of this crowded situation. So we have this wonderful flexibility and ability to create these scenes that cause difficulty again in the comfort and safety of our clinics.

Virtual reality in rehabilitation

I did a quick PubMed search, and you can see here that the number of articles since 1993 to today have grown exponentially. And so we know that virtual reality is a valid rehabilitation method.

Treatment protocols

So here you could see a woman that's doing cognitive tasks with her right hand, just a red mushroom zoom with her left hand. She has to hit blue mushrooms. And so that can be a little bit challenging, right? So we add that cognitive task and here, you can see another example where we're popping balloons.

I like this one because in this task you have to pop the green balloons, but not pop the yellow balloons. So that cognitive task kind of reminds me of what we think about when we think about saccadometry and the assessment protocol where we tell the patient, don't look at the target, but look away.

So these cognitive tests added again that challenge, trying to dig out those, you know, difficulties that are hidden behind some of the easier tasks.

So if we want to take a nice clear example of a dual task now, so here you see a patient on a platform that moves in so they can be walking along and when they're moving, they're going to be, you know, see in the video.

Let me get it started for you. They're going to be this bird and they're going to fly through these targets to these circles. Right. So difficult enough to be able to do that. Then we can add a second dual task that we hand the patient a net and then we tell them to watch out for the butterflies.

And when they see the butterflies, we want them to take that net. They have a remote control in their hand. We want them to take that net and start capturing those butterflies. Right? So now they have two tasks. They got to maneuver through the circles. Wow. Looking for and catching those butterflies.

So it's really easy in virtual reality to have all these different kinds of activities and games. They're fun. Patients love them, but at the same time that they're having fun, that they're doing this dual task and they're getting themselves better, oftentimes without even realizing that they're exercising or working towards getting themselves better. Right? Feels like they're just playing a game.

Building blocks of virtual reality rehabilitation

So I want us to think about when we're thinking about how do we bring this virtual reality? And then I want us to think about these building blocks. So and just to think about the instruction that we give to the patient, how that patient learns, what we can do to keep them motivated, how we can change the dosage and specificity of the task, and then the need for biofeedback to keep that patient engaged.

1. Instructions

Instructions are straightforward. A patient will perform better if they're given good instructions. Remember to give the patient the instructions before you put the goggles on so that they can see you and understand what they need to do because this will affect their performance.

2. Learning

And then we need to think about how people learn. I just gave one example here of implicit learning. Implicit learning as something that virtual reality gaming can promote and learning without even knowing that you're learning, right? So, being in these complex scenes, playing these games, we're actually learning brains, learning new information without even realizing that we're learning.

3. Motivation

Super important. Keep the patient motivated. In this little video that's playing here, the patients are sitting in an elevator right now. The elevators made of all glass are going to go up and down. And I can change by moving these settings and I can do this very rapidly and many, many different ways.

I could change the color of the glass, could change the color of the floor. I can do all of these small little variations in the patient's experience so that when they're traveling up and down that elevator for the first time, maybe I only have one wall for them to look for.

I thought maybe that's stimulating enough. But as they get used to that situation, maybe I can give them more glass surroundings or all glass surroundings so that they have, you know, more sensory information coming in.

So reducing boredom is the key. See this man looks like he's having a great time. So we want to get that patient up and playing and feeling like they're having a great time. They're learning implicitly without even realizing that they're learning.

They don't get bored, which makes them want to keep going and patient. I'm going to get better if they can do the tasks right. So we need to keep them engaged.

4. Dosage of training

Here's just one more example where you could see in this video a super fun game. So I am the circle, and I am tracking the little planet. And you can see when I made the Circle for my input, for my head smaller, it turns red a lot more, meaning that I'm having a much more difficult time tracking it. Right.

So again, I can go from a big circle and as I get good at that, can shrink it to a small circle and make the task more challenging.

And here I'm moving my head to control. Following that. Right. So super easy to go from something that was really easy, from a really big circle to a really easy task to follow that planet, to a much smaller circle and a much more difficult task.

So this is about dosage, right? So you start with an easy task. And as the patient gets better, if you don't make the task more challenging, it's not going to be useful for them. Right.

5. Task specificity

And then task specificity, pulling the patient into an environment where they have trouble. I have trouble in the car, very carsick. So putting me into a scene where I can experience being in the car, that's useful for me. So we want to pick scenes and experiences that are specific and practical for that person.

So there isn't one protocol that works for everybody. You have to talk to your patient and figure out where their difficulties are and then use the many, many, many different options that you have in the virtual reality to create the scenes that are useful and practical and are going to help that specific patient.

6. Biofeedback

And then biofeedback so important, right? The patient has to be getting some kind of feedback from the system so that they know that they're doing a good job and keep them motivated. Another part of that motivation.

So here you can see this gentleman is doing some shoulder exercises, right? So a little strengthening, shoulder looking at target, some hand-eye coordination. But what's important here is he's getting his score right.

So down here you can see that his best score ever was 331 right now he only has 15. You can see how much time he has left. Right. So this can keep him motivated. I got to hurry up, try to be accurate and get more targets so this biofeedback keeps them in the game, right?

It keeps them going and it keeps them motivated and they need that. So having biofeedback is super important and in virtual reality, biofeedback is there and very easy for the patient.

Conclusions

So to wrap up, virtual reality is a tool that could make our trainings more useful and more specific. Keeping the patient motivated, easy to do, cognitive motor, dual tasking, easy to change things on the fly and keep that patient engaged and provide biofeedback.

But what we need to remember is that it's not as easy as just putting the goggles on, picking any protocol and letting the patient go and assuming that they're going to get better. Remember that the protocols have to be specific to what that patient’s need or area of difficulty or challenges are.

And then we want to remember those building blocks. Right. It's important that we give the patient good instructions. We want to know how they learn. We want to know what keeps them motivated. We want to pay attention to the dosing in the tasking and then always remember to get them some biofeedback to keep them in the game.

Dual tasking is very important. We know that it proves outcomes. There are many, many, many published articles that validate this for us. So we know that virtual reality and dual tasking is a valid strategy that we can use.

Today we talked to more about neurological patients, but in general dual tasking is very helpful and that when we design our protocols or rehabilitate, we think about how we can involve both motor and cognitive skills.