Immersive VR in Stroke Pilot Study
Immersive VR in Stroke Pilot Study
Over 15,000 Veterans are treated by the VA for stroke each year. A stroke means that part of
 the brain dies. Many people who have a stroke have difficulty with moving their arm, using
 their hand, and they have pain. Virtual reality is a video-game based treatment that may help
 people with stroke improve in these areas. Virtual reality involves using a computer and
 goggles to make a person feel like they are in a different world with new sights and sounds,
 relaxing on a beach where there is no pain, or playing the piano. In virtual reality, stroke
 patients can practice movement in a safe and motivating environment. For example, a person
 with stroke who has weakness in his/her arm can safely reach for plates in a virtual
 cupboard. In a virtual environment, the plates can't break. This study will help
 investigators to determine if people with strokes who are treated with virtual reality like
 it, and if they have less pain and better movement.
Background. Over the last decade, Virtual Reality (VR) has emerged as a cutting-edge
 technology in stroke rehabilitation. VR is defined as a type of user-computer interface that
 implements real-time simulation of an activity or environment allowing user interaction via
 multiple sensory modalities. VR interventions in a stroke population have been shown to be
 equivalent to usual care therapies and to enhance motor recovery when utilized as an adjunct.
 Significance/Impact/Innovation. This research will advance knowledge in rehabilitation
 research by testing state-of-the-art immersive 3-dimensional VR technology with the
 post-acute stroke Veteran population. The proposed project addresses: (1) the RR&D goal of
 maximizing functional recovery, (2) interest in non-pharmacological activity-based
 interventions for pain, and (3) supports modernization of the Veterans' Health Administration
 by incorporating technology-assisted rehabilitation.

 Specific Aims. (1) Determine the feasibility and tolerability of using a therapeutic VR
 platform in an inpatient comprehensive stroke rehabilitation program and (2) Estimate the
 initial clinical efficacy, or effect size, associated with the VR platform using APPS for
 distraction and upper extremity exercise for Veterans post-stroke.

 Methodology. Prospective within-subject pre-post pilot and survey study designs will be used.
 The target populations are (1) clinical staff who work on the Comprehensive Interdisciplinary
 Inpatient Rehabilitation Program (CIIRP) at the James A. Haley Veterans' Hospital (JAHVH) in
 Tampa (sample size N=10) and Veterans who are inpatients in the CIIRP (sample size N=10). The
 VR intervention consists of wearing a head mounted display that plays APPs ranging from music
 and nature views for pain distraction to more challenging strengthening and coordination
 activities such as playing the piano virtually. The intervention will last four weeks. The
 analytic approach will use descriptive statistics and qualitative methods. Aim 1 will
 administer a survey with open and closed ended questions to clinicians to examine the
 feasibility of successfully integrating a VR intervention into the flow of usual care.
 Feasibility constructs include adaptability (can VR intervention be adapted to an inpatient
 unit), patient need (do Veterans like and benefit from the intervention), and staff
 comments/impressions. Responses for each construct will be entered into an excel spreadsheet,
 one tab for each construct. Responses will then be grouped by similar content. Results will
 be reported as themes and subthemes. Aim 1 will also track patient VR tolerability by
 documenting and discussing patient complaints and adverse events. Tolerability data will be
 extracted from meeting minutes and grouped by similar occurrences. Results will be reported
 as themes and subthemes. Aim 2 will estimate effect sizes and degree of precision for upper
 extremity neurologic recovery, hand dexterity, and pain outcomes measured pre and post VR
 intervention. Neurologic recovery is measured with the Fugl-Meyer Assessment of Motor
 Recovery after Stroke-Upper Extremity, dexterity is measured with the Action Research Arm
 Test, and pain is measured with the Pain Outcomes Questionnaire-VA. Because standard scores
 do not necessarily translate to meaningful clinical differences (improvements), the
 investigators will identify the proportion of subjects who experience the minimal clinically
 important difference (MCID). Metrics will also be compared across outcomes.

 Next Steps/Implementation. Our next step is to work with our Program Partner in the Physical
 Medicine and Rehabilitation Office to conduct a large multi-site clinical trial that will
 incorporate the lessons learned from this feasibility pilot study to test the efficacy of a
 VR intervention in inpatient rehabilitation and transition to home evironments.
Inclusion Criteria:

 -Veterans who have been diagnosed with

 -  an acute ischemic or hemorrhagic stroke and

 -  post-stroke are admitted to James A. Haley Veterans' Hospital inpatient rehabilitation

 -  age 18-80 with stroke diagnosis verified by brain imaging.

 Exclusion Criteria:

 -  Unable to follow instructions or participate in immersive VR therapy due to
 significant cognitive impairment,

 -  History of seizures.