**6. A clinical trial**

Qualified physiotherapists from the clinical community were employed for the clinical evaluation of the VR-based rehabilitation program. They also helped to recruit the research subjects for the work, and supervised their training sessions. The patients were required to use the virtual environment for regular rehabilitation for about half an hour per day, five days a week for a period of four consecutive weeks. A computer screen provided the therapists with feedback on the performance of the patient on the system, and the therapists were able to adjust the level of difficulty of each exercise based on the specific need of the individual patient. Adjustment was in terms of what the author termed Task Difficulty Level (TDL), which ranged from 1, the easiest to 4, the most difficult. The therapists observed the progress made by the patients while they performed the VR tasks, and also guided them in producing more refined movements to reduce movement errors. The clinical trial was carried out at the Sir John Golding Rehabilitation Centre, popularly known as Mona Rehab. Mona Rehab is a unique center for the rehabilitation of persons with physical disabilities in the Caribbean, and it is only a short distance from the researcher's place of work, which made it easily accessible. The researcher installed the system in the Physical Therapy Department. The patients' gait variables were obtained prior to and after the treatment, and were analyzed and used to ascertain the usefulness of virtual reality technology in rehabilitation program directed towards lower extremity problems in post-acute stroke patients. A test was carried out to determine whether skills gained within VR environments transfer to the real world.

## **7. The virtual environment system**

The VR system executes and displays a welcome screen where user of the system will have to enter a password in order to gain access. The screen dump below shows the first interface of the system which the users, in the clinical trial case, the physical therapists, will use to gain access to the systems.

A valid password has been stored in the memory, which the system compares with the user's supplied password. A mismatch will allow the user two more attempts before the system logs out. A match will lead the user to the Patient Information Screen. The user will be required to

operating system. It offers complete independence from network protocols and topologies. Application developers are well shielded from underlying hardware as OpenGL drivers ensure proper encapsulation of hardware primitives, thus giving them ample flexibilities for innovative designs. The OpenGL standard provides language binding for C++ and Java, the two main languages employed for the research study. The virtual exercise system incorporated performance-based target levels to increase the patients' motivation (Jack et al., 2001). Feedback mechanisms informed the patients on the target levels and their actual performance on the VR system, and the therapists employed the GUI-based interface to tailor exercise difficulty to the patients' specific problems. The feedback provided an avenue for encouraging the patient to accomplish more trials in the virtual environment. To encourage motivating environment, the author identified, through interviewing the patients, that music will make the scenario of interest to them, and combined an audio system with the painting exercise, in a way that presented an interesting and motivating environment where the patients were unaware of the technology behind the VR-based exercise, just because they wanted to 'play the game' on the computer and enjoy the music.

Qualified physiotherapists from the clinical community were employed for the clinical evaluation of the VR-based rehabilitation program. They also helped to recruit the research subjects for the work, and supervised their training sessions. The patients were required to use the virtual environment for regular rehabilitation for about half an hour per day, five days a week for a period of four consecutive weeks. A computer screen provided the therapists with feedback on the performance of the patient on the system, and the therapists were able to adjust the level of difficulty of each exercise based on the specific need of the individual patient. Adjustment was in terms of what the author termed Task Difficulty Level (TDL), which ranged from 1, the easiest to 4, the most difficult. The therapists observed the progress made by the patients while they performed the VR tasks, and also guided them in producing more refined movements to reduce movement errors. The clinical trial was carried out at the Sir John Golding Rehabilitation Centre, popularly known as Mona Rehab. Mona Rehab is a unique center for the rehabilitation of persons with physical disabilities in the Caribbean, and it is only a short distance from the researcher's place of work, which made it easily accessible. The researcher installed the system in the Physical Therapy Department. The patients' gait variables were obtained prior to and after the treatment, and were analyzed and used to ascertain the usefulness of virtual reality technology in rehabilitation program directed towards lower extremity problems in post-acute stroke patients. A test was carried out to

determine whether skills gained within VR environments transfer to the real world.

The VR system executes and displays a welcome screen where user of the system will have to enter a password in order to gain access. The screen dump below shows the first interface of the system which the users, in the clinical trial case, the physical therapists, will use to

A valid password has been stored in the memory, which the system compares with the user's supplied password. A mismatch will allow the user two more attempts before the system logs out. A match will lead the user to the Patient Information Screen. The user will be required to

**7. The virtual environment system** 

gain access to the systems.

**6. A clinical trial** 

Fig. 5. The Interface for the Clinician. (Akinladejo, 2005).

supply a patient research number (PRN). If a PRN is not found, the system will give opportunity to either re-enter another PRN or add the current PRN to the database. There is an optional button to exit the program. If a PRN is found or is added, the system then leads the user to the Task Difficulty Level (TDL) screen where the user will specify the appropriate VRbased task that the chosen patient will undergo. The tasks range from one (1) the easiest to four (4), the most difficult. If an invalid TDL is entered, the system will default to TDL1.

The clinician can opt to change the patient from this screen or exit the program. The appropriate TDL choice leads to the exercise mode, where the patient performs the chosen exercise at its TDL level. The exercise mode displays the name of the current patient, the exercise type he or she is performing, the target time for that exercise and the time the patient starts the exercise. The exercise is to cover a window area with a blind, in the form of paint. The TDL of the VR exercise presents the patients with four different rectangular windows that they need to cover with a red blind. As the patients move the cursor over the window using their legs, the window is being covered with the red blind; hence, the patients paint the window area with the mouse until the window is completely covered. The system informs the patients once the window is completely covered, and displays the target time to complete the chosen TDL, the patients' start time, stop time and time taken to cover the window. The user can reset the exercise for the patient or exit the system using the exit button. On exit, the system writes the patients exercise data in an output file, which the author exports to an external application for analysis. The task difficulty level is influenced by the fact that the windows are of different sizes and the 'paint brush' has varying sized tips. These pose challenges in terms of the time and effort required to cover the windows. For example, TDL 1 has a wider window size and a thicker paintb\rush, while TDL 4 has a smaller window size and a thinner paintbrush.

Virtual Environments in Physical Therapy 13

Fig. 8. A Completed Task of Difficulty level 1 by a Patient in the Virtual Environment.

(Akinladejo, 2005).

Fig. 9. The Clinical Site. (Akinladejo, 2005).

Fig. 6. The patient views this window in the virtual environment using the 3D i-glasses. (Akinladejo, 2005).


Fig. 7. A sample of an exercise being performed in the virtual environment by one patient. (Akinladejo, 2005)

Fig. 6. The patient views this window in the virtual environment using the 3D i-glasses.

Fig. 7. A sample of an exercise being performed in the virtual environment by one patient.

(Akinladejo, 2005).

(Akinladejo, 2005)

Fig. 8. A Completed Task of Difficulty level 1 by a Patient in the Virtual Environment. (Akinladejo, 2005).

Fig. 9. The Clinical Site. (Akinladejo, 2005).

Virtual Environments in Physical Therapy 15

A number of analysis were carried out during the study and results obtained, details of which have been presented as in Akinladejo (2005). This chapter presents two results on two

For the exercise sessions in the virtual environment, the percentage of improvement in using the system was calculated based on the patients' performance data for the last day of week

LastDayData (Week2) – LastDayData (Week4) x 100 %

LastDayData (Week2)

Time taken on TDL 3 in

Time taken on TDL 3 in

The following are the percentage improvements for the patients on the VR task over the four-week period (note that improvement addresses the percentage reduction in time taken

51 21x 100% RB1 59% improvement <sup>51</sup>

40 – 12x 100% EO2 70% improvement <sup>40</sup>

secs

RB1 365 302 161 449 1277 21 EO2 165 225 138 212 740 12

Time taken on TDL 4 in

Time taken on TDL 4 in

secs

Total time on exercise for the day in secs

Total time on exercise for the day in secs

Total time on exercise for the day in minutes

Total time on exercise for the day in minutes

secs

secs

RB1 1007 594 545 885 3031 51 EO2 831 416 691 472 2410 40

**8. The research results** 

**8.1 Performance results** 

Patient Time taken

Patient Time taken

secs

secs

The table below summarize the data.

on TDL 1 in

Table 1. Last Day Data for Week Two

on TDL 1 in

Table 2. Last Day Data for Week Four

to complete the task in the virtual environment).

of the patients who used the virtual environment.

two and that of week four on the painting exercise. That is,

Time taken on TDL 2 in

Time taken on TDL 2 in

secs

secs

Fig. 10. A Physical Therapist Guiding a Patient in the Virtual Environment. (Akinladejo, 2005)

Fig. 11. Another Patient in the Virtual Environment. (Akinladejo, 2005).

#### **8. The research results**

14 Virtual Reality and Environments

Fig. 10. A Physical Therapist Guiding a Patient in the Virtual Environment. (Akinladejo, 2005)

Fig. 11. Another Patient in the Virtual Environment. (Akinladejo, 2005).

A number of analysis were carried out during the study and results obtained, details of which have been presented as in Akinladejo (2005). This chapter presents two results on two of the patients who used the virtual environment.

#### **8.1 Performance results**

For the exercise sessions in the virtual environment, the percentage of improvement in using the system was calculated based on the patients' performance data for the last day of week two and that of week four on the painting exercise. That is,

LastDayData (Week2) – LastDayData (Week4) x 100 %

LastDayData (Week2)

The table below summarize the data.


Table 1. Last Day Data for Week Two


Table 2. Last Day Data for Week Four

The following are the percentage improvements for the patients on the VR task over the four-week period (note that improvement addresses the percentage reduction in time taken to complete the task in the virtual environment).

$$\begin{aligned} \text{RB1} &= \frac{51 - 21 \ge 100\%}{51} = 59\% \text{ improvement} \\\\ \text{EO2} &= \frac{40 - 12 \ge 100\%}{40} = 70\% \text{ improvement} \end{aligned}$$

Virtual Environments in Physical Therapy 17

Pre-Gait Theta Pattern Post-Gait Theta Pattern

0 20 40 60 80

The pre‐ and post‐intervention gait pattern for patient EO2

Before the intervention program, using the Kaltenborn's convention, patient RB1's **Range of Motion (ROM) was 8-0-4 as against the normal values 15-0-20** (see Whittle, 2003 for normal ranges for gait parameters). **The ROM was improved to 15-0-8 after the intervention program.** This means that patient RB1 had reduced dorsiflexion and plantar flexion due to spasticity before the intervention program but his ankle joint gained more movements after

Patient EO2's ROM was 27-0-10 before the intervention but changed to 25-0-14 (normal values are 15-0-20). This means that his excessive dorsiflexion 27 was reduced to 25, and he had increased plantar flexion. Excessive dorsiflexion has been linked with tibia tilt, which presents a challenge for normal walking, hence the improvement observed in his walking skill.

The transfer-of-skill observational measurements were carried out by one of the three physical therapists that supervised the clinical trial. The patients were followed up one week after the intervention program to observe whether the skills learnt transferred to the real world. Patients EO2 and LP3 transferred similar skills to the natural environment. They initially had mass movement of the limbs due to sluggish brain activity/coordination. It was observed that these patients were able to move their ankle joints on the floor, without


**9. Interpretation** 

the program.

**10. The transfer of skill result** 

Fig. 13. Graph for Patient EO2. (Akinladejo, 2005).


0

10

20

30

All the patients could not complete the four different levels of the VR task during the first week of the exercise. However, at the end of the second week, their performances had improved, and they were all able to complete the tasks at all the levels. Results from the analysis of the exercise data of the last day of week two and the last day of week four as in table 1 and 2 show that patient EO2 made the most improvement on the VR task(i.e. spent less time completing the task), while patient LP3 made the least improvement. EO2 diligently studied the painting movement and acquired the method of the painting process during the implementation period, hence the result. LP3, however, struggled until the last week before he started improving on the painting process. This result is significant to their functional gains as explained subsequently.

#### **8.2 The clinical results**

The gait variables of the patients were captured using the Polhemus Electromagnetic Tracker System before and after the intervention using the virtual environment, and Kaltenborn's convention (Akinladejo, 2005) was used to interpret the results. The graphs below were obtained for the two of the patients.
