Clinical Profile :
Simon H Schless
PhD, Director of Motion Laboratory
ALYN Hospital, Jerusalem, Israel
Where is your clinic/research institution located?
The Movement Analysis and Biofeedback laboratory is located in the ALYN Hospital Pediatric and Adolescent Rehabilitation Center in Jerusalem. ALYN Hospital specializes in pediatric rehabilitation, treating a broad spectrum of common and rare pathologies. More information about ALYN Hospital can be found at https://www.alyn.org/.
What patient populations do you serve? How many per year?
In our first year of using the Movement Analysis and Biofeedback laboratory (Jan 2019 – Jan 2020), we performed over 150 clinical gait analyses and 16 biofeedback training protocols, all with virtual reality visual stimuli. Common patient populations include cerebral palsy, spina bifida, traumatic brain injury, osteosarcoma, and other orthopedic diagnoses.
What VR rehab system(s) do you have installed?
We are using Motekforce Link’s Gait Realtime Analysis Interactive Lab (GRAIL) (https://www.motekmedical.com/product/grail/) virtual reality (VR) system. It is configured with 10 optical motion tracking cameras (Vicon®, UK), a 16 channel wireless surface electromyography system (Delsys®, USA) and an instrumented split-belt treadmill with four degrees of freedom (pitch and medial/lateral translations) and two embedded force plates. In front of the treadmill is a 180º curved screen that together with a projection on to the treadmill itself and a surround sound system, provides an immersive environment. We have found this to be particularly crucial for motivating younger patient populations and to avoid the feeling of repetitiveness or boredom during treatment.
What benefits do you gain from using this VR rehab system?
The VR system is designed to support daily clinical use. It enables real-time calculation of synchronized joint kinematics, kinetics and muscle activity during gait, greatly reducing the usually lengthy post-processing time. Visual engagement from the various projected environments appears to evoke a more natural walking pattern when combined with a constantly adapting self-paced algorithm that accommodates children’s natural variability in walking speed. We collect large quantities of gait cycles for analysis (50 per leg), further improving the overall accuracy and enhancing clinical interpretation. Our biofeedback training protocols consist of six to twelve sessions over a short period of time. Objectives range from targeting normalization of gait via visual and auditory feedback to dual-tasking and perturbation training to prepare a patient for reintegration into their activities of daily life.
Are you involved in clinical research using VR rehab systems? If so, please describe briefly.
Clinical research is very important to us at ALYN Hospital. We are currently using an application whereby a three-dimensional avatar based on a live stream of the patient’s joint kinematics is projected on to the screen in front of them. While sitting, standing and walking the patient receives immediate visual and auditory feedback in accordance with specific training aims. Currently, we have an ongoing project for patients with orthopedic pathologies. These populations were chosen as their impairments appear to stem from pain avoidance and muscle weakness in the early stages of their rehabilitation, but persist long after the pain decreases and muscles strengthen. We have found that just twelve repetitive training sessions (three times per week for a month) on a single task, such as reducing a Trendelenburg gait pattern, can be much more effective with the use of VR. This was also supported by patient reports of satisfaction with treatment; in particular, they appreciate the ability to see how they are walking over an extended period of time and to learn how to adapt that pattern.
What do you see as the most important challenge for VR rehab research and development?
From our experience, there are three challenges of integrating VR into the pediatric rehabilitation setting that need to be explored further. The first relates to the duration of each VR training session. Currently, each session lasts for 45 minutes based on a combination of what is clinically feasible and not overly demanding for our young patients. The second is related to the quantity of VR training sessions. The decision to implement protocols of six to twelve sessions is a compromise between sufficient repetition in the desired VR training and burnout of patient motivation. Even though we see immediate positive effects from the VR training, the overall combination of training duration and intensity, and how that influences the long-term transfer into real-world ability remains to be further explored. The third is related to the age of the patients, in particular the development of engaging and clinically relevant VR training for younger children ages 4-7.
(Original article source: ISVR Newsletter Issue 17)