Proof of Concept to Use A Virtual Reality Game in Rehabilitation of Stroke Patients in Neuro ICU in TTSH

Year Submitted: 2025
Published Date: 08 April 2025

Tags: Technology, Care Process ＆ Redesign, Rehabilitative Care

About this Content

Aims

1. Improve their muscle strength to the premorbid status as measured by a single physiotherapist using the Medical Research Council (MRC) grading.
2. Increase the frequency (number of sessions in ICU) and intensity (ensure every suitable patient does 20 minutes of physiotherapy) of physiotherapy for each patient by 20% for their stay in ICU. This is based on historical data from our internal audit that each patient receives 2.5 physio-led sessions of physiotherapy over an average of 5 days of ICU stay.

Background

Currently, there are minimal PT/ OT-led rehabilitation activities in NICU/NHD. Reasons include:
• Acuity of patients with unstable haemodynamic parameters
• Poor GCS with inability to follow commands and loss of core muscle strength
• Shortage of manpower resource to start rehab in ICU

Large potential to improve this and thus patient outcome
• Rehab activities include sitting up in bed, sitting out of bed, assistance from sit to stand, ability to use the Moto-med cycle machine, and early mobilisation within the ICU/HD premise.
• Previous TTSH Rehab study showed that a commercial virtual reality (VR) game appeared to be a feasible adjunctive therapy in stroke rehabilitation in the outpatient settings. There is no such VR-based programme for acute stroke patients in ICU.
• AHA/ASA (2014) recommended “range-of-motion activities, motor challenges and seated activities” commencing within 24 hours after stroke to prevent deconditioning, hypostatic pneumonia, orthostatic intolerance, and depression.
• VR game would allow patients to benefit even at bedside with fine and gross motor movement rehab of upper and lower limbs. (E.g. reaching out to pick a virtual flower, kicking a virtual ball etc.)

We aim to harness a virtual reality (VR) game in rehabilitation of stroke patients in Neuro ICU/HD as proof-of-concept pilot study in 20 patients.

Methods

Chosen a virtual reality rehab equipment available in the market to assess the feasibility.

Developed a study protocol to identify eligible patients and obtained DSRB approval.

a. ICU/HDU nurses screen all stroke patients admitted to their ward using eligible criteria set forth by the study protocol
b. Physiotherapist reviewed the patients for suitability to use VR rehab equipment
c. Eligible patients who consented proceed to use virtual reality to improve movement of upper and lower limbs daily under supervision of PT or PT assistant trained to use VR rehab equipment.
d. Track and record number of session and total duration of rehab session with VR rehab game equipment alongside monitoring of untoward side effects
e. Physiotherapist reviewed the patients to record motor strength of shoulder and knee and functional status score for ICU (FSS-ICU) upon transfer out of the unit

Results

During study duration (29July 2020 till 2Mar 2021), a total of 68 stroke patients were screened and referred by ICU/HDU nurses. 45 were assessed by physiotherapists to be eligible to participate in the project.

24 consented to take part in the study, of which only 4 were found to have other weakness or cardiovascular deterioration related to the disease process that limited them from using VR rehab equipment. These 4 patients nonetheless received the traditional physiotherapy session.

20 patients successfully received VR rehab sessions (minimum 20 minutes) in addition to the traditional PT/OT sessions and none requested to stop or there was no early termination of VR rehab sessions from untoward side effects.

Lessons Learnt

Virtual reality rehab equipment can be used by stroke patients for rehab sessions when carefully selected. Early termination of VR rehab sessions was not warranted in any of 20 patients based on the study protocol.

The equipment is mobile and can be pushed to bedside to start rehab early. This brought forward the early initiation of rehab sessions for critically ill patients who still require continuous monitoring.

Other factors affecting the successful participation such as truncal weakness was picked up during implementation that helped to fine-tune the selection criteria of suitable cases in future.

Keywords

Stroke rehab, Virtual Reality rehab, early rehabilitation, cognitive/neurosensory rehabilitation

Innovators' Details

Connect with this contributor!

Dr Wong Yu-Lin - Yu_lin_wong@ttsh.com.sg

Project Attachment