Home-based Upper Extremity Stroke Therapy Using a Multiuser Virtual Reality Environment: A Randomized Trial

Published:November 09, 2019DOI:



      To compare participation and subjective experience of participants in both home-based multiuser virtual reality (VR) therapy and home-based single-user (SU) VR therapy.


      Crossover, randomized trial.


      Initial training and evaluations occurred in a rehabilitation hospital; the interventions took place in participants’ homes.


      Survivors of stroke with chronic upper extremity impairment (N=20).


      Four weeks of in-home treatment using a custom, multiuser virtual reality system (VERGE): 2 weeks of both multiuser (MU) and SU versions of VERGE. The order of presentation of SU and MU versions was randomized such that participants were divided into 2 groups, First MU and First SU.

      Main Outcome Measures

      We measured arm displacement during each session (m) as the primary outcome measure. Secondary outcome measures include time participants spent using each MU and SU VERGE and Intrinsic Motivation Inventory scores. Fugl-Meyer Assessment of Motor Recovery After Stroke Upper Extremity (FMA-UE) score and compliance with prescribed training were also evaluated. Measures were recorded before, midway, and after the treatment. Activity and movement were measured during each training session.


      Arm displacement during a session was significantly affected the mode of therapy (MU: 414.6m, SU: 327.0m, P=.019). Compliance was very high (99% compliance for MU mode and 89% for SU mode). Within a given session, participants spent significantly more time training in the MU mode than in the SU mode (P=.04). FMA-UE score improved significantly across all participants (Δ3.2, P=.001).


      Multiuser VR exercises may provide an effective means of extending clinical therapy into the home.


      List of abbreviations:

      ANOVA (analysis of variance), BREQ-2 (Behavioral Regulation in Exercise Questionnaire), FMA-UE (Fugl-Meyer Assessment of Motor Recovery After Stroke for the Upper Extremity), IMI (Intrinsic Motivation Inventory), MU (multiuser), SU (single-user), VERGE (Virtual Environment for Rehabilitative Gaming Exercises), VR (virtual reality)
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        • Benjamin E.J.
        • Blaha M.J.
        • Chiuve S.E.
        • et al.
        Heart disease and stroke statistics-2017 update: a report from the American Heart Association.
        Circulation. 2017; 135: e146-e603
        • Dobkin B.H.
        Rehabilitation after stroke.
        N Engl J Med. 2005; 352: 1677-1684
        • Ottenbacher K.J.
        • Smith P.M.
        • Illig S.B.
        • Linn R.T.
        • Ostir G.V.
        • Granger C.V.
        Trends in length of stay, living setting, functional outcome, and mortality following medical rehabilitation.
        JAMA. 2004; 292: 1687-1695
        • Health Resources and Services Administration
        Rural health profession facts: supply and distribution of health professions in rural America.
        Health Resources and Services Administration, Rockville1992
        • US Department of Health and Human Services
        Distribution of U.S. health care providers residing in rural and urban areas.
        (Available at:) (Accessed March 11, 2019)
        • Liao Y.
        • Greenlund K.J.
        • Croft J.B.
        • Keenan N.L.
        • Giles W.H.
        Factors explaining excess stroke prevalence in the US Stroke Belt.
        Stroke. 2009; 40: 3336-3341
        • Hopman W.M.
        • Verner J.
        Quality of life during and after inpatient stroke rehabilitation.
        Stroke. 2003; 34: 801-805
        • Duncan P.
        • Richards L.
        • Wallace D.
        • et al.
        A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke.
        Stroke. 1998; 29: 2055-2060
        • Jurkiewicz M.T.
        • Marzolini S.
        • Oh P.
        Adherence to a home-based exercise program for individuals after stroke.
        Top Stroke Rehabil. 2011; 18: 277-284
        • Sluijs E.M.
        • Kok G.J.
        • van der Zee J.
        Correlates of exercise compliance in physical therapy.
        Phys Ther. 1993; 73 ([discussion 83-6]): 771-782
        • Chen C.Y.
        • Neufeld P.S.
        • Feely C.A.
        • Skinner C.S.
        Factors influencing compliance with home exercise programs among patients with upper-extremity impairment.
        Am J Occup Ther. 1999; 53: 171-180
        • Wittmann F.
        • Held J.P.
        • Lambercy O.
        • et al.
        Self-directed arm therapy at home after stroke with a sensor-based virtual reality training system.
        J Neuroeng Rehabil. 2016; 13: 75
        • Dodakian L.
        • McKenzie A.L.
        • Le V.
        • et al.
        A home-based telerehabilitation program for patients with stroke.
        Neurorehabil Neural Repair. 2017; 31: 923-933
        • Piron L.
        • Turolla A.
        • Agostini M.
        • et al.
        Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach.
        J Rehabil Med. 2009; 41: 1016-1020
        • Holden M.K.
        • Dyar T.A.
        • Dayan-Cimadoro L.
        Telerehabilitation using a virtual environment improves upper extremity function in patients with stroke.
        IEEE Trans Neural Syst Rehabil Eng. 2007; 15: 36-42
        • Andrade K.O.
        • Martins J.
        • Caurin G.A.
        • Joaquim R.C.
        • Fernandes G.
        • Relative performance analysis for robot rehabilitation procedure with two simultaneous users
        Proceedings of the IEEE RAS & EMBS International Conference on Biomedical Robotics and Biomechatronics; 2012 Jun 24-27.
        IEEE, Rome2012
        • Caurin G.A.
        • Siqueira A.A.
        • Andrade K.O.
        • Joaquim R.C.
        • Krebs H.I.
        Adaptive strategy for multi-user robotic rehabilitation games.
        Conf Proc IEEE Eng Med Biol Soc. 2011; 2011: 1395-1398
        • Gorsic M.
        • Cikajlo I.
        • Goljar N.
        • Novak D.
        A multisession evaluation of an adaptive competitive arm rehabilitation game.
        J Neuroeng Rehabil. 2017; 14: 128
        • Gorsic M.
        • Cikajlo I.
        • Novak D.
        Competitive and cooperative arm rehabilitation games played by a patient and unimpaired person: effects on motivation and exercise intensity.
        J Neuroeng Rehabil. 2017; 14: 23
        • Le H.H.
        • Loureiro R.C.V.
        • Dussopt F.
        • Philips N.
        • Zivanovic A.
        • Loomes M.J.
        • Soundscape and haptic cues in an interactive painting: a study with autistic children
        Proceedings of the IEEE RAS & EMBS International Conference on Biomedical Robotics and Biomechatronics; 2014 Aug 12-15.
        IEEE, Rome2014
        • Mace M.
        • Kinany N.
        • Rinne P.
        • Rayner A.
        • Bentley P.
        • Burdet E.
        Balancing the playing field: collaborative gaming for physical training.
        J Neuroeng Rehabil. 2017; 14: 116
        • Novak D.
        • Nagle A.
        • Keller U.
        • Riener R.
        Increasing motivation in robot-aided arm rehabilitation with competitive and cooperative gameplay.
        J Neuroeng Rehabil. 2014; 11: 64
        • Andrade K.O.
        • Fernandes G.
        • Martins J.
        • Roma V.
        • Joaquim R.C.
        • Caurin G.A.
        • Rehabilitation robotics and serious games: an initial architecture for simultaneous players
        Proceedings of the Biosignals and Biorobotics Conference (BRC); 2013 Feb 18-20.
        IEEE, Rio de Janerio2013
        • Pires F.A.
        • Santos W.M.
        • Andrade K.O.
        • Caurin G.A.
        • Siqueira A.A.
        • Robotic platform for telerehabilitation studies based on unity game engine
        Proceedings of the IEEE 3rd International Conference on Serious Games and Applications for Health; 2014 May14-16.
        IEEE, Rio de Janeiro2014
        • Cikajlo I.
        • Rudolf M.
        • Goljar N.
        • Burger H.
        • Matjačić Z.
        Telerehabilitation using virtual reality task can improve balance in patients with stroke.
        Disabil Rehabil. 2012; 34: 13-18
        • Triandafilou K.M.
        • Tsoupikova D.
        • Barry A.J.
        • Thielbar K.N.
        • Stoykov N.
        • Kamper D.G.
        Development of a 3D, networked multi-user virtual reality environment for home therapy after stroke.
        J Neuroeng Rehabil. 2018; 15: 88
        • Gowland C.
        • Stratford P.
        • Ward M.
        • et al.
        Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment.
        Stroke. 1993; 24: 58-63
        • Markland D.
        • Tobin V.
        A modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation.
        J Sport Exerc Psychol. 2004; 26: 191-196
        • Tsuopikova D.
        • Triandafilou K.
        • Solanki S.
        • Barry A.
        • Preuss F.
        • Kamper D.
        • Real-time diagnostic data in multi-user virtual reality post-stroke therapy
        Proceedings of the SIGGRAPH ASIA 2016 VR Showcase; 2016 Dec 5-8.
        ACM, Macao2016
        • Fugl-Meyer A.R.
        • Jääskö L.
        • Leyman I.
        • Olsson S.
        • Steglind S.
        The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance.
        Scand J Rehabil Med. 1975; 7: 13-31
        • McAuley E.
        • Duncan T.
        • Tammen V.V.
        Psychometric properties of the Intrinsic Motivation Inventory in a competitive sport setting: a confirmatory factor analysis.
        Res Q Exerc Sport. 1989; 60: 48-58
        • Norman G.
        Likert scales, levels of measurement and the "laws" of statistics.
        Adv Health Sci Educ Theory Pract. 2010; 15: 625-632
        • Likert R.
        A technique for the measurement of attitudes.
        Arch Psychol. 1932; 22: 140-155
        • Lang C.E.
        • Macdonald J.R.
        • Reisman D.S.
        • et al.
        Observation of amounts of movement practice provided during stroke rehabilitation.
        Arch Phys Med Rehabil. 2009; 90: 1692-1698
        • Lo A.C.
        • Guarino P.D.
        • Richards L.G.
        • et al.
        Robot-assisted therapy for long-term upper-limb impairment after stroke.
        N Engl J Med. 2010; 362: 1772-1783
        • Klamroth-Marganska V.
        • Blanco J.
        • Campen K.
        • et al.
        Three-dimensional, task-specific robot therapy of the arm after stroke: a multicentre, parallel-group randomised trial.
        Lancet Neurol. 2014; 13: 159-166
        • Wittmann F.
        • Lambercy O.
        • Gonzenbach R.R.
        • et al.
        • Assessment-driven arm therapy at home using an IMU-based virtual reality system
        Proceedings of the Rehabilitation Robotics (ICORR), 2015 IEEE International Conference.
        IEEE, Singapore2015 Aug 11-14
        • Chan L.
        • Sandel M.E.
        • Jette A.M.
        • et al.
        Does postacute care site matter? A longitudinal study assessing functional recovery after a stroke.
        Arch Phys Med Rehabil. 2013; 94: 622-629