Author(s): Joel Stein, MD, Katherine Rief, MD, Darcey Hull, DO
Originally published: September 20, 2014 Last updated: April 20, 2023
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Overview and Description

Definition

Robotics and virtual reality are increasingly utilized in rehabilitation medicine to facilitate and complement conventional rehabilitation strategies.

A robot can be defined as “a machine that performs various complex acts of a human being” and “automatically performs complicated, often repetitive, tasks.”1 Current robotic systems include therapeutic robots, such as workstation exercise robots, and wearable exoskeletal robots (powered braces). There are also assistant-robots for activities of daily living (ADL), instrumental activities of daily living (iADLs), and companion robots.2

Virtual reality (VR) is defined as a human-computer interface that allows a user to interact with a computer-generated environment, using multiple sensory channels.3,4 The virtual environment (VE) can provide users with visual, auditory, or tactile feedback. Current systems vary in size, scope and level of immersion.  An example of non-immersive VR would be a flat-screen system, whereas immersive VR would be a head-mounted visual display (HMD)5.  Additionally, therapeutic games are used for rehabilitative purposes, which focus on skill- or knowledge-development.  They are typically accessed through commercially available interactive gaming consoles (e.g., Nintendo’s Switch, or Microsoft’s Xbox).  Some virtual reality applications now use smartphones as both an interactive visual environment and also a data recording device, allowing measurements of movement and function to be collected in the virtual environment, making the technology more versatile and accessible.6

Augmented reality (AR) adds digital elements to a live view through devices like cell phones, tablets, or wearable lenses. Examples include projector-based representation of prosthetic limbs for amputees and multidimensional maps with superimposed labels and information. Unlike VR which creates a separate environment, AR adds a digital layer to reality. Different types of AR exist on a continuum from unaltered reality to a fully virtual environment. A variety of motion tracking sensors or cameras have been developed in order to incorporate user movement and position.

Conceptual model

In the field of rehabilitation medicine, robotics and VR systems have the potential to measure abilities and serve as therapeutic tools. These systems can measure motor abilities, posture and limb position, strength, gait, and balance. Real-time feedback, as well as longitudinal reports of progress can be generated.  This objective data can help the clinician guide further therapy. Therapeutically, they provide users with repetitive, contextualized, task-specific training in a stimulating and entertaining manner, promoting neuroplasticity and recovery.7 With advances in Machine Learning and Artificial Intelligence, there will be more adaptive solutions to progressively increasing challenge and complexity of VR, AR, and robotic therapeutic activities for patients, creating more personalized interventions.  Additionally, the engaging presentation of the otherwise repetitive or mundane task with game-like interfaces may assist with compliance with therapy programs. There are also successful Vocational Rehabilitation applications of VR for patients with physical disabilities.8

Furthermore, robotic systems can facilitate or assist movement of paretic limbs in performing functional movements, enabling patients to increase social engagement and increase autonomy and independence. VR systems (such as Valve Index, Oculus, Meta, and Kinect) can provide cognitive exercises and measures as well as simulation of real-world activities in a safe context (e.g., driving simulation of car or wheelchair, street crossing, working in a kitchen, wayfinding).9 Combining robotics and VR systems, the benefits of both technologies can be realized, providing precise, repetitive training in engaging, safe virtual environments.

Targeted disorders

Robotic and VR systems have primarily been studied for use in patients with motor and sensory disorders of the central and peripheral nervous system (CNS), including stroke, traumatic brain injury (TBI), multiple sclerosis (MS), spinal cord injury (SCI), cerebral palsy (CP), Parkinson’s disease (PD), amyotrophic lateral sclerosis (ALS), chronic peripheral neuropathies (PN), cognitive dysfunction (COG), certain psychiatric disorders, chronic pain, and also muscular dystrophies (MD), musculoskeletal disease (MSKEL), patient education and post-amputation

Robotic systems are uniquely suited to provide functional assistance with mobility and activities of daily living. For example, robotic exoskeletons can allow paraplegic individuals with SCI to walk independently. Brain-computer interfaces, where computers analyze brain signals from EEG or implanted electrodes and use them to control robotic devices, computers, or other communication interfaces, are being studied for patients with ALS, SCI, CP, brainstem stroke, SCI, MD, PN10, 11 Robotic systems can also serve as companions with social, psychological and physiological benefits12, 13

VR systems are also being used in the field of musculoskeletal and sports medicine in order to provide an engaging, structured environment for performing strengthening, stretching, cardiovascular exercise, and for prosthetic training. Additionally, VR systems have been used to treat cognitive disorders resulting from acute and neurodegenerative disease, specifically with improvement in executive functions and visuospatial abilities14.An emerging area is the use of VR for acute and chronic pain both in adults and children. VR is also being used for psychiatric disorders, such as post-traumatic stress disorder, which may affect patients needing rehabilitation.

Relevance to Clinical Practice

Clinical justification for use

Repetitive, high intensity task-specific training has been shown to spur neuroplasticity and functional recovery post-stroke. Typically, this is achieved by a team of physicians and therapists. This traditional approach is time and labor intensive.  With VR, AR, and robotics, these therapies could potentially become partially automated, more data-driven, reproducible, and cost effective.   These emerging modalities can be used in acute as well as chronic rehabilitation as a supplement to conventional therapy.  Evidence regarding robotics and VR is still too limited to provide definitive clinical practice recommendations, and it remains unclear whether incorporation is more beneficial at one stage of rehabilitation than others.  Robotic, VR, and AR modalities offer options for inpatient, outpatient, and home-based settings.  Workstation robots and gait trainers are stationary due to their large sizes and are used to provide therapeutic exercise, in the clinic setting.  Portable VR, AR, and robotic devices may be used in all settings.

For the lower extremities, robot-delivered body weight-supported treadmill training has been used for gait training. There is some evidence for use of robot-assisted gait training in patients with CVA, PD, CP, and SCI15,16.  In addition VR rehabilitation training may lead to better performance in terms of gait and balance in patients with PD than does isolated traditional therapy17.  In a study of powered exoskeletal robots for the lower extremities in patients with motor complete SCI, exoskeletal robots were shown to be safe and well tolerated, and participants were able to walk independently for periods of five to ten minutes with reported physical and psychological benefits18.  Additional studies have shown improvement in bowel function19, improved bone density20 cardiovascular benefits, improvement of spasticity, pain, and bladder function18,21.

Wearable powered orthoses can serve both functional and therapeutic goals by compensating for a patient’s neurological deficits while training muscles and coordination. Stroke patients using an electromyogram (EMG)-controlled exoskeletal upper limb-powered orthosis showed improvement in function and spasticity.22 A randomized controlled multisite trial of post-stroke patients with a chronic paretic arm examined task-oriented training with the use of an exoskeletal robot and showed improvement in upper extremity function that was superior to conventional treatment23. One study for upper extremity robotic systems for shoulder and elbow rehabilitation in stroke patients in acute rehabilitation facilities showed benefits lasting three years.24 Another study showed improvements in both subacute and chronic population.25 Robotics may be able to help increase training intensity, and also increase repetitions of exercises. 

In addition to their roles as exercise training devices and as functional orthoses, robots can provide assistance with ADLs.  One commercially available example is the Obi™ (Jacksonville, FL) feeder, a single-purpose robotic device used to promote feeding assistance to tetraplegic individuals.  Wheelchair-mounted robotic arms, such as the JACO™ (Kinova, Canada) are available, but control mechanisms are laborious to operate.  More autonomous robots could, in principle perform activities of daily living, such as retrieving an item for the user, or other ADL-related-errands.  These devices remain largely experimental at present, however.  Lastly social robots can perform supervisory tasks, or function as a companion. These robots remain limited in function and are not yet widely adopted.  The popular ROOMBA™ (iRobot, Bedford, MA) robots can be used in the iADLs of vacuuming the floor or mowing the lawn, and SIRI™ (Apple) can be used for making phone calls, internet searches, and verbally dictating emails without physical contact.

There is evidence of both cognitive and upper extremity motor gains using the VR with the RAPAEL™ smart glove (Neofect).26 Additionally, patients with severe TBI in early recovery states were found to have had attentional improvements when using a VR environment with tactile cues27.  For VR systems, research has been most extensive for treatment of motor impairments due to stroke.28,29,30 A 2011 Cochrane review found that VR was more effective than conventional therapy in retraining upper limb function and with improving ADL function; however, no statistically significant increase in grip strength or gait speed was found.30 Randomized controlled trials have examined the benefit of VR following a stroke. The efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST) trial failed to show improvement of upper extremity motor abilities or functional/ADL differences when VR was used as an add-on therapy to standard task-oriented recreational activities.31 VR training for upper extremity in subacute stroke (VIRTUES) trial, a multicenter RCT, showed improvement in upper extremity motor function in both the VR and standard therapy groups but no differences between the groups.32 The two groups were in subacute phase of stroke approximately a month after their stroke and received equivalent total treatment time of therapy.  Gaming and VR systems can be used for telerehabilitation, with improved upper extremity motor function when dose- and intensity-matched to therapy delivered in a clinical setting.33  

A 2018 Cochrane review of electromechanical and robotic arm training following stroke showed improved arm function and ADL scores compared to usual care, though the clinical impact of these differences is unclear. More recently, a multi-site randomized controlled clinical trial (RATULS) was performed in the UK to compare robotic therapy, enhanced upper extremity limb therapy and usual care.34 Using a rigorous design and large sample size, this study did not find improvement in upper extremity motor impairments nor improved ability to perform ADLs with the use of robotics. Limitations of this study include a relatively chronic population (mean duration > 6 months), and relatively severe motor impairments. Also, the use of a particular robotic system, based on the MIT-MANUS system, may not reflect the potential for benefit from other robotic devices.

In terms of pain management, VR can provide distraction during painful stimulus, decreasing pain perception, possibly reducing need for pain medication, and facilitating participation in therapies. In terms of chronic pain, VR can also help in managing complex regional pain syndrome, phantom limb pain, cancer pain, and chronic low back pain. VR is also being used in conjunction with desensitization therapy in patients with fibromyalgia to alter pain processing and central sensitization.  There is evidence that adult burn patients experience significant subjective improvement in pain when using VR during range of motion (ROM) activities in therapy35.  Patients with cancer pain had a spectrum of responses to VR for pain relief.  Participants who experienced reduction in their perception of pain through VR tended to prefer either cognitive-engagement or relaxation-based VR experiences, but not both. Effects were also noted mostly during use of VR, rarely lasting beyond the end of the VR experience, though some subjects felt their sleep-quality improved, and others felt their mobility had improved. 36 Patients with chronic lower back pain experienced clinically meaningful improvement in their pain up to 3 months after an 8-week self-administered therapeutic VR program37.  Phantom Limb Pain was also significantly improved with VR.38 

In addition to the motor, sensory, attentional, and visuo-spatial training, VR can also be used to assess and perform additional cognitive exercises to work on other aspects of executive function like memory and planning.3 The technology also has been studied in multiple simulation settings with virtual offices, kitchens and driving environments.3 Within the pediatric population, VR has been used among children with CP, and was found to be effective in improving engagement and motor function, proximal stability, postural tone and range of motion.39, 40

In terms of AR, some surgeons are using superimposed AR to demonstrate surgical procedures as an educational tool prior to surgery.  Robots assist and increase precision in surgery in a variety of applications in recent years (DaVinci® robot (Intuitive Surgical Inc.) in general and gynecologic surgery, Mako™ robot for orthopedics (Stryker). AR may be implemented as an educational and simulation tool for patients in therapy inpatient, outpatient, and home-based. Rehabilitation applications for AR are still early in their development.

Factors that influence clinical application

Historically, robotics and VR systems have often been inaccessible for routine clinical use due to high cost of technologies. For VR, consumer-oriented gaming consoles provide a low-cost means of accessing this technology conveniently from home, although medically oriented systems remain more expensive.  Robotic rehabilitation systems remain quite expensive at this time, limiting access.  Another issue for these technologies is that most reach the market in the US through the FDA’s 510(k) process that does not require demonstration of efficacy in rigorous clinical trials.  As a result, there is typically insufficient evidence of their actual clinical efficacy for clinicians to make evidence-based decisions regarding their use.  Ongoing advances in technology include decreasing bulk, weight, ease of donning and doffing, improvement of aesthetics, and portability and reliability of power sources. While robotic therapy and VR have been shown to be superior to “usual care” (typically involving little or no active therapy) in a number of studies, there is little convincing evidence that they are superior to dose-matched conventional rehabilitation therapy.41, 42 Lastly, while these technologies have the potential to provide labor savings and potentially financial savings, these benefits remain difficult to achieve with existing technologies, most of which continue to require considerable supervision by a trained clinician.

Potential disadvantages and adverse effects

A general limitation to these technologies is that patients with cognitive, visual, and perceptual impairments may find them difficult to use.15 In terms of robotics, safety issues are critical to consider, especially given that primary user groups have functional deficits that may make them vulnerable to technological malfunctioning, especially if unsupervised. Several safety mechanisms have been employed in robotics in order to prevent injury. For instance, some systems are compliant and back-drivable, allowing the user to “push back” if the device attempts to move them in an undesired way.  Easily available shut-offs, and mechanical fail-safes to prevent excessive forces are also used in many devices.  Padding is also utilized to decrease pressure and potential for skin injury. There have also been concerns for increased risk of fracture while using adjustable exoskeletons and gait training systems in patients with osteoporosis. While there are case reports of fractures due to weight bearing in this context, insufficient data exist to confidently predict the risk to individual patients, though some studies have used as exclusionary criteria such as osteoporosis (t score <-2.5 at the femoral neck) 18 or a lower extremity fracture within the past year.43 Overall, rehabilitation robots have had a very impressive safety record, and no serious injuries have been reported from their use.

With regard to VR, few adverse events are reported, such that VR appears to be an inherently safe therapeutic modality. The most common adverse effect is transient visually-induced motion sickness, known as cybersickness. Symptoms are similar to motion sickness, but generally less severe.3,30 Cyber sickness occurs more frequently with immersive VR. However, some degree of tolerance-development to cybersickness has been reported.36 Occasionally, patient may also complain of transient eye strain.28 There are no explicit contraindications for VR. However, caution is warranted with patients who have communication disorders which may prevent one from identifying discomfort during the intervention; or with patients with certain psychiatric disorders, such as anxiety or delusions. VR systems may pose a risk of falls for patients using these while standing, and appropriate supervision and precautions should be taken. 

Cutting Edge/ Unique Concepts/ Emerging Issues

Both robotics and virtual reality, individually or in combination, can potentially provide a wide range of therapies in an engaging and cost-effective manner. In countries with a rapidly aging population, such as Japan, emphasis is being placed on robot technology to fill the gap created by an insufficient number of caregivers.44 Additionally there are an expanding number of VR programs delivered to patients at home via telehealth, expanded in popularity and options due to the COVID-19 pandemic. At this point these at-home telehealth VR programs are primarily targeted towards patients with orthopedic diagnoses, post-arthroplasty and for patients with cognitive impairments as well45. Virtual reality was also used for patients with COVID-19 who were admitted to the hospital46.  The VERITAS (Virtual Exercise Rehabilitation In-home Therapy: A Research Study) showed similar clinical outcomes in patients after total knee replacement who received virtual therapy, with a cost savings of nearly $3,000 per patient compared with traditional clinic physical therapy.47 As more evidence suggests cost-savings with similar clinical outcomes and patient satisfaction in specific populations, this model is likely to expand to other areas of rehabilitation. A limitation of VR applications is that very few are able to offer haptic feedback, which is likely of great value in the therapeutic rehabilitation process48.  Surface EMG may also emerge as a method by which VR and AR interfaces may be controlled, which may help to determine readiness to use a myoelectric prosthesis.  Emerging issues involve concerns for accessibility, cost, patient autonomy, and privacy, as well as the potential use/misuse of these technologies to replace rather than supplement the skilled practitioner. Compassionate care is an invaluable component of the rehabilitation process, and one that is unlikely to be automated in the near future.  As technology becomes more available and affordable, it is probably that more rehabilitation-focused technologies will appear in the market without rigorous scientific testing and development. 

Gaps in Knowledge/ Evidence Base­

Additional research is required to further investigate robotic and VR systems in order to determine which designs are most efficacious for different populations, the appropriate dosing and timing of intervention, as well as motivation and adherence to therapeutic programs. Methodologically, current research efforts in the field of robotics and VR are limited by heterogeneity among interventional approaches, outcome measures, control groups, and nomenclature,49 limiting the ability to pool and compare studies, or build on previous research.50 Also, thorough description of the technical aspects of AR/VR and robotic systems should be included in the methods sections of research papers.51  Additionally, these studies generally utilize small sample sizes, and few studies have examined whether effects are sustained. One review of clinical trials of robot rehabilitation showed that most studies were suboptimally designed, contributing to the dearth of phase II and III clinical trials.52 VR studies have also illuminated the challenge of generalizing conclusions about VR-efficacy, such that conclusions can only be made about the specific VR system studied, not about all VR.53  There also appears to be a gap in the research in terms of whether virtual and augmentative reality programs may increase patient participation in at-home physical, occupational and speech therapy practice, and thus generalization of skills learned in therapy.  Also, there is often limited funding in the area of rehabilitation research, and treatment using robotics is currently not well-reimbursed.54 Compounding the challenges of clinical research in robotic rehabilitation is the constant and rapid advances in these technologies. More rigorous pathways for evaluation of novel robotic systems may need to be considered so that patients can benefit from up-to-date technological advances while ensuring that they are both safe and effective. 

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Original Version of the Topic

Joel Stein, MD, Hannah Aura Shoval, MD, Ethan Rand, MD. Virtual reality-robotic applications in rehabilitation. 9/20/2014

Previous Revision(s) of the Topic

Joel Stein, MD, Katherine Rief, MD. Virtual reality-robotic applications in rehabilitation. 7/30/2020

Author Disclosure

Joel Stein, MD
BrainQ, Inc.; Research Support; Site investigator in clinical trial, steering committee member for the clinical trial

Katherine Rief, MD
Nothing to Disclose

Darcey Hull, DO
Nothing to Disclose