Motor Learning through Virtual Reality
"We are what we do repeatedly, so excellence is never an act but a habit.
Since the 1970s, Virtual Reality (VR) has been used for technical gestural training in the military and space fields. What is learned can be transposed to real life [1] and learning can be repeated endlessly with almost no human and material risk and with potentially greater benefits. 2] How does VR help motor learning in pathological situations and which patients could benefit from it?
Throughout life, the nervous system changes its structure and function through brain plasticity. Sensory stimuli induce the regeneration of synaptic connections and its effects on the organism shape these interactions to optimize motor responses. Thus, the more tangible the experiences, the more the brain will integrate the motor responses [3]. It is this phenomenon that allows an amputee to integrate a prosthesis [4].
The reasoned practice in physiotherapy requires 3 phases to optimize motor learning [5]. Motor learning is built before, during and after an exercise. Before proposing an exercise to the patient, the practitioner must make sure that the conditions are met for the good realization of the exercise: does the patient understand the instruction? Can he/she perform the task that is being asked of him/her? Does this gesture mean something to the patient and will it be beneficial to him/her? An exercise that answers negatively to one of these points will put the patient in a situation of failure without any benefit for the learning.
VR allows exercises to be tailored to the needs of the patient at a given moment. The parameters in space, time and progression can be modified ad infinitum, and the computer support allows recording to the nearest millimetre and tenth of a degree. Any physical progression, even the slightest, can thus be quantified and objectified. Once the conditions for success have been established, the patient will be able to repeat the exact same exercise as many times as necessary, at different times, thus facilitating gestural learning. [3]
The practitioner establishes, from the patient's abilities, exercises and will propose their adaptation in real time according to his reactions. The practitioner determines the quantity, the complexity and the schedule.
The patient needs feedback on their efforts. The question, "Was it good? "often comes up. This question may reflect the superiority of brain processing of motivation over kinesiophobia. The patient's attention is diverted from the anticipation of pain, which leads to the inhibition of cholecystokinin secretion, particularly in chronic pain pathologies [6]. VR will provide an immediate answer to this question by displaying a score in real time. At the end of the session, it allows quantifying a success rate that can be used as motivation for future sessions. Finally, the continuous recording of the data from the sessions carried out will make it possible to quantify the long-term evolution and demonstrate to the patient, as well as to the prescriber, the progress made, however slight.
VR therapy is more than a simple game with a sequence of exercises that replaces the practitioner. The current solutions allow an adaptation of the parameters of the exercises in real time to the capacities of the patient: fatigue and pain. The practitioner keeps his expertise and this tool enhances his practice both with the patient, who remains accompanied, and with prescribers who will have a precise feedback on the patient's progress.
Thus, whether in neurological, orthopedic or rheumatological pathologies, VR provides reproducibility of sessions over time and their instantaneous modulation to adapt to clinical observations with the objective of optimal stimulation of brain plasticity. It is a tool that facilitates the management of the physiotherapist without being able to replace him.
Philippe Gilmer, Physiotherapist- Osteopath, Trainer-Consultant, Virtualis
BIBLIOGRAPHY :
[1] Training in virtual environments: Transfer to real world tasks and equivalence to real task training. F D Rose, E A Attree, B M Brooks, D M PArslow, P R Penn, N Ambihaipahan DOI: 10.1080/001401300184378
2] Virtual Environments for Motor Rehabilitation: Review MAUREEN K. HOLDEN, Ph.D. CYBERPSYCHOLOGY & BEHAVIOR Volume 8, Number 3, 2005
3] The effect of virtual reality-based balance training on motor learning and postural control in healthy adults: a randomized preliminary study. Prasertsakul, T., Kaimuk, P., Chinjenpradit, W. et al. BioMed Eng OnLine 17, 124 (2018). https://doi.org/10.1186/s12938-018-0550-0
[4] H. Head and G. Holmes. Sensory disturbances from cerebral lesion. Brain, 34(2-3):102-254, 1911.
5] Principles of motor learning in treatment of motor speech disorders. Maas E, Robin DA, Austermann Hula SN, et al. Am J Speech Lang Pathol. 2008;17(3):277-298. DOI:10.1044/1058-0360(2008/025)
6] Chronic low back pain managed by virtual reality and technological innovations. Stéphane FABRI Kinésithérapie Scientifique 2019 ; 611 :11-19