Keywords

1 Introduction

A stroke is a life-threatening emergency condition that results in acute symptoms of focal damage to the brain, spinal cord, or retina. It represents a very significant social problem. Every year 90 thousand people in Poland suffer a stroke, while in the world it is 17 million. Moreover, there is an increase in the number of cases in young and middle-aged people. An important side of this condition is also the social aspect. Stroke is the first cause of morbidity, long-term disability, and epilepsy in the elderly [1]. It is also the second cause of dementia and the second cause of death [2]. Complications following stroke include cardiac, pulmonary, gastrointestinal, musculoskeletal, neurological complications, and other not classified complications like fatigue, depression, or fever [3]. A complication that affects about 25–30% of patients is unilateral hemispheric neglect syndrome [4]. This is a disorder of spatial attention in which the perception of and response to stimuli from the part of the body opposite to the location of the stroke focus are reduced. The consequence of this syndrome is increased length of hospitalization and increased cost of care [5]. This is due to the need for comprehensive rehabilitation [6].

Community-based, outpatient, and home-based rehabilitation enable improved functioning, acquisition of new self-care skills, and partial or complete recovery of independence [7]. The extent of rehabilitation should always be tailored to the needs of the patient. The goal of physiotherapy in a patient with a motor deficit, whether resulting from damage to the primary motor cortex or more complex, is to restore motor skills or compensate for them. Movement deficits can be addressed directly by movement therapy with active patient participation. The guidelines for stroke management mention rehabilitation with virtual reality, indicating that there are high hopes for this form of rehabilitation [6]. Studies show that using immersive VR for the general rehabilitation of stroke patients improves their balance, reduces the risk of falls, and improves the perception of visual verticality [8]. Other studies indicate that VR can reduce upper limb motor disabilities [9, 10] and can encourage physical activity and social participation [11, 12].

2 Methods

2.1 Rehabilitation in Semi-neglect Syndrome

Neurological physiotherapists indicate that during exercises for unilateral atrophy syndrome, various stimuli should be involved: auditory and visual, which should direct the patient’s attention to the neglected side. It is important that both limb exercises on the neglected side and visuospatial search training be adapted to the patient’s altered or, if possible, corrected midline. The eye or limb movement should be progressively performed from the non-skipped side towards the skipped side (to a line or fixed point/object that is clearly visible to the patient) [13].

The first exercises should be based on grasping objects with the non-neglected side and transferring them, by crossing the midline, to the neglected side. Subsequent exercises can also be based on grasping objects with the neglected side and transferring them to the neglected side - the alternating handwork of crossing the midline is intended to make the brain aware of the neglected side again.

2.2 VR-Based Application for After-Stroke Complications

Based on the above physiotherapists’ guidelines, a VR game was developed (Fig. 1.). It was located in a quiet, open forest area, which allows the patient to relax while receiving physiotherapy treatments. The aim of the game is to collect apples placed on the trees and place them in the boxes appearing on the opposite side. It is important to note that red apples can only be picked with the right hand and green apples with the left hand (if you try to grab an apple with the opposite hand, the box will not appear).

Fig. 1.
figure 1

VR game for a patient with hemineglect, unilateral neglect syndrome

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Figure 1 shows that the patient’s task is to grab a green apple with his left hand and move it to the crate on the right. During this movement, there is a crossing of the midline and a visual search of the space on the neglected side. Additionally, correctly locating the box and hitting it with the apple is reinforced with a haptic stimulus in the form of a vibrating controller. At the same time, the patient may also attempt to grasp the red apples with the other hand and move them to the opposite side. The ability to grasp with both the active and inactive side also helps to train manual dexterity of the neglected side.

During the game, the patient can check his progress by monitoring the statistics: the number of green apples collected, the number of red apples collected, the percentage of apples correctly thrown, and the average time from collecting any/red/green apples to throwing them into the box.

The game created in this way was presented to a team of neurological rehabilitation specialists working at the Department of Neurology and Stroke Unit of the University Clinical Hospital in Białystok, composed of Agnieszka Zieziula, M.Sc. in physiotherapy, Izabela Zalesko, M.Sc. in physiotherapy, and Justyna Karpińska, M.Sc. in physiotherapy (Fig. 2.).

Fig. 2.
figure 2

Game testing by a team of physiotherapists

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3 Results and Conclusion

After testing, the game was commented on by a team of physiotherapists. In their opinion, it has potential in the rehabilitation of patients with upper limb paresis as well as a certain group of patients affected by unilateral spatial neglect syndrome. In the case of unilateral atrophy, the target group could be patients in the home rehabilitation stage. Among the advantages of the developed application, physiotherapists emphasize the correct course of movement of the upper limb, as well as the frequent crossing of the center line. In addition to the physiotherapeutic elements, specialists also note the pleasant environment, which can contribute to prolonged physiotherapy time. This is consistent with many other studies that indicate the effectiveness of using VR games in rehabilitating various neurological conditions, such as Parkinson’s disease [14], spinal cord injury [15], and phantom pain [16]. In addition to improvements in physical performance, many studies also indicate greater satisfaction with physiotherapy among patients and more willingness to exercise, which translates not only into improvements in physical fitness but also in mental health [17, 18]. In the case of hospital patients, a simpler version of the game would be necessary - exclusion of movement in the game, limitation of control to one hand, and higher color contrast. This is due to the greater limitations of these patients and the need for better adaptation to their requirements.

3.1 Further Steps

It is planned to develop the application so that it is adapted to the needs of patients in hospital neurological and stroke wards. As part of the customization of the app, it is primarily planned to simplify the game. In the game under development, the patient should not have to move around the environment. In addition, the game should be able to be operated with a single controller. Significantly from the point of view of physiotherapy, the destination - the box, should appear in different locations.