VR4NEUROPAIN: Interactive Rehabilitation System

Micaela Fonseca

1,2,3,4

, Heitor Cardoso

, Nuno Ferreira

, Tiago Loureiro

, Inês Gomes

and Claudia Quaresma

1,2,*

Departamento de Física, Faculdade de Ciências e Tecnologia, Universidade Nova de Lisboa,

2892-516 Monte da Caparica, Portugal

Laboratório de Instrumentação, Engenharia Biomédica e Física da Radiação (LIBPhys-UNL), Departamento de Física,

Faculdade de Ciências e Tecnologia, Universidade Nova de Lisboa, 2892-516 Monte da Caparica, Portugal

VR4NeuroPain, Rua Comandante António Feio nº26 1C1, 2800-255 Almada, Portugal

Universidade Europeia, Laureate International Universities, Estrada da Correia, nº53, 1500-210 Lisboa, Portugal

Collide, Avenida D. João II, nº 43, 9º. 1990-084 Lisboa, Portugal

IMG - Strategy Branding Visual Communication, Avª Oscar Monteiro Torres 16, 2.ºD, 1000-219 Lisboa, Portugal

tiagoloureiro@collide.rocks, gomes.iim@gmail.com, q.claudia@fct.unl.pt

Keywords: Rehabilitation, Spinal Cord Injury, Software, Neuropathic Pain, Virtual Reality, Gaming.

Abstract: Virtual Reality (VR) has finally found its way to be used in the healthcare industry, covering many different

areas such as medical training, marketing, patient education, psychotherapy and physiotherapy, and many

others. The need to develop increasingly personalized technology to be used during the rehabilitation

process is extremely important. Therefore, the VR4NeuroPain solution aims to cover the unique influence

that it obtains from the VR applied to the rehabilitation area, creating unique and virtual spaces where

patients with neuropathic pain can be submitted to their therapy sessions, not only in hospitals and clinics,

but also at home. The VR4NeuroPain system monitors electrophysiological data in real time, and consists of

the following components: Virtual Reality Interface, Plataform and a Glove-“GNeuroPathy”. The main

objective of this paper is to describe all the components of VR4NeuroPain solution. The system can be used

by physicians, occupational therapists and physiotherapists. VR4Neuropain allows the use of innovative and

interactive intervention methodologies.

1 INTRODUCTION

VR4NeuroPain is a customized solution of

interactive technology that aims to promote the

rehabilitation of patients with neuropathic pain in a

hospital or home environment. This innovative

system combines virtual reality headsets, haptic

feedback gloves with motion and biomedical sensors

allowing the collection and analysis of physiological

parameters. This approach while is used as a

rehabilitation facilitator, the patient is also immersed

into a virtual world where he can perform several

gamified tasks. These required tasks are specified

physical exercises prescribed and recommended by

therapists under conventional therapy but with the

plus of the virtual reality world engagement that

increase the patient motivation.

VR4NeuroPain aims to promote rehabilitation of

Stroke patients, Spinal cord Injury patients,

Neuropathic Pain, physiotherapy, as also promote

active ageing.

The stroke is one of the main disability factors of

the upper member causing functional losses

associated with cognitive and perceptual disorders

(Thrift, 2017). With the currently used intervention

methods in the conventional rehabilitation process,

30% to 60% of the individuals that suffered a stroke

will not regain their competencies effectively.

Worldwide, the incidence of Spinal cord Injury

ranges from 3.6 to 195 per million leading to a major

medical problem (Massetti, 2018).

Neuropathic pain is a type of chronic pain caused

by damage or disease affecting the central nervous

system and can affect anyone. It manifests itself in

various ways such as burning sensation, weight,

needle sting and shocks. Up to 7% to 8% of the

European population is affected by neuropathic pain

(Liedgens, 2016). Among people in the US reporting

at least some pain in the last year, 15.7% likely had a

Fonseca, M., Cardoso, H., Ferreira, N., Loureiro, T., Gomes, I. and Quaresma, C.

VR4NEUROPAIN: Interactive Rehabilitation System.

DOI: 10.5220/0007581402850290

In Proceedings of the 12th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2019), pages 285-290

ISBN: 978-989-758-353-7

285

syndrome with a neuropathic component

(DiBonaventura, 2017).

Laver et al. (2012) refer that virtual reality seems

to be a promising technology, however, currently,

the studies are few and do not ensure the

occupational interests of individuals, nor allow an

active participation of caregivers. Computer games

will be part of the future of healthcare and

personalised healthcare system (Yannakakis, 2012).

The games should be integrated into contingency

plans for its high potential (Mc Callum, 2012).

On the other hand, the acquisition of biosignals

has been increasingly used to monitor the

physiological and biomechanical parameters, thus

helping, in the definition of the intervention plan.

So, the human activity monitoring by wearable

electronic equipment is a new research area and it

has been growing constantly over the past years.

This approach is possible due to the easy self-

adapting sensors, which provide the collected data to

be processed to obtain the relevant analysis of the

biosignals. Furthermore, the optimal combination of

the sensors used (less as possible) and the data

collected (much as possible) could provide a simple,

but complete, health monitoring system.

Despite the portable systems are easy to use with

these procedures, when monitoring requires

extensive periods of time, the use of wearables

devices is the most suitable method. Its

implementation has a severe impact on some health

assessment and interventions on the patient's and on

the patient's clinical evolution.

Aligned with the wearable devices and the

ubiquitous computing resources, the opportunity to

use biofeedback therapy emerged. Biofeedback is a

technique of training in which a person learns how

to control involuntary bodily functions using the

devices and it is increasingly used in clinical.

Therefore, the real-time acquisition enables the

subject to control involuntary bodily functions and

the clinician can monitor in a real context.

So, biosignals and virtual reality, due to their

impact importance, are relevant methodologies to be

applied in rehabilitation

Therefore, an innovative solution was developed

named "VR4NeuroPain", which associates virtual

reality with sensory and motor stimulation

(Quaresma, 2018). The system consists of the

following components: Virtual Reality Interface,

Platform and a Glove - "GNeuroPathy", that

monitors electrophysiological data in real time.

The "VR4NeuroPain" system was developed to

play an active role in the rehabilitation process,

promoting patients' quality of life and well-being. It

is based on the following therapeutic objectives:

 Performing fine and global movement;

 Distinguish tactile sensory stimuli;

The "VR4NeuroPain" also aims to motivate the

rehabilitation process and stimulate technological

literacy.

For that reason, the use of interactive

technologies in rehabilitation process allows to

reduce the time spent in that process and greater

economic sustainability of the units of the health

sector. In order to guarantee the applicability of the

system it is necessary to carry out the validation of

all the components. Therefore, one of the

components of the "VR4NeuroPain" is the

"GNeuroPathy" and has already been applied in

people with no associated pathology and it has been

found to be easy to apply and meets the proposed

objectives (Quaresma et al., 2018).

It allows the integration in the conventional

rehabilitation of interactive and playful

methodologies that are in tandem with the

motivations and occupational interests of the

patients.

2 MATERIAL AND METHODS

The study was approved by the Portuguese Ethics

Committee of the Medicine and Rehabilitation

Center of Alcoitão, in Portugal.

The components of VR4NeuroPain solution are

(Figure 1): Haptic feedback Device, Glove

“GNeuroPathy” System, VR4NeuroPain Platform

and VR Game.

Figure 1: VR4NeuroPain Solution components.

2.1 Haptic Feedback Device

For the haptic feedback device will be used the

ESP32 BLE (development Board WiFi+Bluetooth

Ultra Low Power Consumption - Dual Cores) placed

inside a wrist band and wired connected to 5 small

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vibrator motors (4.0 cm x 1.0 cm x 0.3 cm / Rated

Voltage: DC 3.0V) embedded in the underside of

each “GNeuroPathy” glove's fingers.

This device will be powered by a 3.7v battery

while is bluetooth paired with the developed

software providing different vibration patterns for

each several virtual stimulus controlled by the

therapist.

Figure 2: On the left - esp32 development board with

Bluetooth low energy embedded (BLE).

On the right - the vibration motors that will be

placed inside the glove's fingers.

2.2 Glove “GNeuroPathy” System

The "GNeuroPathy" system is a glove that monitors

electrophysiological data in real time. During the

design process of "GNeuroPathy" it was necessary

to take into account a set of requirements. Therefore,

it was decided that the "GNeuroPathy" should:

 Allow integration of muscle activity with

eletri-miography (EMG) and electro-dermal

activity (EDA) sensors and not interfere

with therapy performance.

 Be portable.

 Be light, comfortable and not interfere with

the tasks performed by the subject. must be

adaptable to various sizes of hand.

 Allowing a more real interaction with the

subject and the object being manipulated.

 Be cheap for use by doctors and patients.

 Recreating a different sense of touch.

The "GNeuroPathy" glove (Figure 3) is easy to

put on, allows object manipulation and integrates

two types of sensors that collect EDA and EMG

data. To record the EMG and EDA signals, a

Bitalino * acquisition module, 2 EMG sensors and 2

EDA sensors were used. To connect the sensors to

the subject, 2 Ag / AgCL with adhesive electrodes

nailed with solid adhesive were used by sensor

(TIGA-MED Gold 01-7500, TIGA-MED GMBH,

Germany).

Usability validation that examines subject’s

degree of satisfaction when using the glove

(Quaresma et al., 2018).

Figure 3: The glove "GNeuroPathy”.

Bitalino (Figure 4) records the biological signals

simultaneously with a 16-bit resolution and

sampling frequencies up to 1000 Hz. All data is

transmitted via Bluetooth. To record the data

transmitted from Bitalino, the software used was

Plux OpenSignals.

Figure 4: The components of the Bitalino and the EDA

sensors (Guerreiro et al., 2013; Guerreiro et al., 2014).

2.3 VR4NeuroPain Platform

The VR4NeuroPain platform is a responsive web-

based solution and has the objective to help promote

the rehabilitation of patients with neuropathic pain,

through integration with the VR4NeuroPain solution

(Figure 5). The platform can be used on desktops,

laptops, tablets or mobile phones.

The VR4NeuroPain platform is composed of a

database where is recorded all the information about

patients, physicians, rehabilitation sessions

schedules, configuration parameters for virtual

reality games and scenarios, and other important

information. The platform has also many user-

friendly web pages created for registered users to

manage all the necessary information.

The platform allows access to two types of users:

clinicians (such us physicians/occupational,

therapists) and platform administrators.

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287

The physicians/occupational therapists can record

all clinical information of patients such as age,

diagnosis, evaluation of rehabilitation parameters for

patient sessions. They can also manage the schedule

of their patient’s rehabilitation sessions and have

also access to reports and dashboards to assess the

evolution of the patients.

The administrators manage the VR4NeuroPain

platform, doing operations like configuring new

users to access the platform, manage all

rehabilitation sessions schedule, payments of

sessions and they are also responsible in the

configuration of all parameters of virtual reality

games and scenarios used in VR4NeuroPain

rehabilitation sessions and based on physicians

requests.

Figure 5: The VR4NeuroPain Platform.

The VR4NeuroPain platform was created using

WordPress which is a free and open-source content

management system (CMS) based on PHP and

MySQL. Wordpress is used by more than 60 million

websites and is the the most popular website

management system in use. Some areas of the

VR4NeuroPain platform were customized using a

template and applying several programming

languages such as PHP, HTML, JavaScript and CSS.

The database was based on MySQL which is an

open-source relational database management system

(RDBMS). To create the database the language

chosen was SQL.

2.4 VR4NeuroPain Game

Virtual Reality has great capabilities in person’s

embodiment and sense of presence inside virtual

environments (Pozeg, 2017), where the user can

really feel that they’re living that virtual experience.

Because of this, VR become commonly used among

medical treatments due the fact that the virtual

environment variables are more likely to be

controllable and repeated. From phobias (Banos,

2002), motor cortex rehabilitation due stroke

conditions (Alves, 2018) to spinal-cord injury

focused either in neuropathic pain improvements

(Villiger, 2013), studies have shown that this

technique is sustainably promising.

For example, (Villiger, 2013) found that Two

thirds of the patients improved, immediately after

the treatment and 12 to 16 weeks after treatment,

showing long term effects, probably due beneficial

effects of visual illusions on pain as they point on

this study.

Said that, we expect either positive results with

our approach, once literature present positive

evidences.

The VR4NeuroPain game is a VR real-time

rendering application made with the Unity engine,

that enables neuropathic pain patients to undergo

physical therapy at hospitals, clinics and also at

home. By tracking the patient’s movements and bio-

signals, the app is capable of monitoring posture,

tracking therapy performance, correlate exercises

with bio-signals and much more.

By using the Leap Motion interface as means to

interact with the virtual environment we are

removing the need for another physical interface to

be used by the patient, thus allowing for a more

natural and intuitive human machine interface

(HMI) that will not require the adaptation of hand-

based exercises. Interactivity with the environment

has been designed so that patients mimic everyday

actions like pressing buttons or moving levers each

time they are interacting with the virtual world.

Project Chatrooms is a multiplayer, multiplatform

framework that enables multiple users to connect to

the same virtual space and interact with one another.

As such, it makes VR multiplayer development

faster, easier, affordable and customized for

developers.This framework is Hardware Agnostic -

runs on all VR hardware and non-VR on PC and

Mac; Engine Agnostic - Unity and Unreal engines

supported; Multiplayer Services Agnostic - Photon,

GameSparks, SpatialOS or any other solution and

supports Haptic gear and other VR specific

equipment.

Thanks to the Project Chatrooms multiplayer VR

framework, VR4NeuroPain may have health

professionals following patients in real-time from

anywhere in the world. Not only are they capable of

joining the same virtual world (and therapy session)

to monitor the patient’s exercises, but they also have

real-time access to the patient’s bio-signals.

2.5 Branding

VR4NeuroPain is a state-of-art scientific product

with a commercial purpose that aims to upgrade

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neuropathic patients therapies with portable therapy.

As it's about to improve patients quality of life, the

brand identity strategy was based on how important

was to keep the visual message straight and effective

to those who will benefit on it.

Figure 6: The VR4NeuroPain Game.

2.5.1 Brand Visual Solution

The approach to the graphic identity solution comes

down to the visual translation of the users

experience - VR Glasses, which take the patient to a

virtual therapy room, and biosensors gloves that

connect that virtual reality with tactile stimulation

(Figure 7).

Round and smooth shapes illustrates the flow of

this experience with a real human purpose, and at

the same time an hidden matrix structuring different

levels of information.

The brand will predominantly live on screens, so

using gradients was an opportunity to reinforce the

flow concept and to make it feel bright and alive.

Dark blue and electric green were combined as a

positive standout palette that can grow over time.

In application, it’s mostly about the gradient

offset rounded shapes demanding the attention of

VR4NeuroPain main asset - sensory vibration -

which can be sized and cropped in different layouts

that create tension and make good use of free space.

Figure 7: Brand visual solution.

3 CONCLUSIONS

The principal objective of this article is to present an

ongoing project for system development named

"VR4NeuroPain". In order to guarantee the

applicability of the system it is necessary to carry

out the validation of all the components.

In the future will be developed software with

algorithms of processing of physiological signals,

such us EDA and EMG. These algorithms must

allow the correlation of the mentioned biosignals. In

addition, the glove - "GNeuroPathy" must also be

validated associated with the other parts of the

system. Tests in individuals with neuropathic pain

will be performed with the "VR4NeuroPain" and

compared with the conventional procedure in order

to prove that this is a reliable system.

The system can be used by multiple users and

will allow us to apply innovative and interactive

methodologies of intervention promoting the process

of rehabilitation.

ACKNOWLEDGEMENTS

The authors would like to thank all the healthcare

professionals of Medicine and Rehabilitation Center

of Alcoitão. The authors would like to thank Collide

for the help and support provided in this

investigation.

REFERENCES

Alves, S. S., Ocamoto, G. N., de Camargo, P. S., Santos,

A. T. S., & Terra, A. M. S. V. (2018). Effects of

virtual reality and motor imagery techniques using

Fugl Meyer Assessment scale in post-stroke patients.

International Journal of Therapy and Rehabilitation,

25(11), 587–596.doi:10.12968/ijtr.2018.25.11.587

Banos, R. M., Botella, C., Perpina, C., Alcaniz, M.,

Lozano, J. A., Osma, J., & Gallardo, M. (2002).

Virtual reality treatment of flying phobia. IEEE

Transactions on Information Technology in

Biomedicine, 6(3), 206–212.

doi:10.1109/titb.2002.802380

DiBonaventura MD, Sadosky A, Concialdi K, et al. The

prevalence of probable neuropathic pain in the US:

results from a multimodal general-population health

survey. J Pain Res. 2017;10:2525-2538. Published

2017 Nov 1. doi:10.2147/JPR.S127014

Guerreiro, J., Martins, R., Silva, H., Loureno, A., Fred,

A. 2013 BITalino: A Multimodal Platform for

Physiological Computing. Proc of the Int’l Conference

VR4NEUROPAIN: Interactive Rehabilitation System

289

on Informatics in Control, Automation and Robotics

(ICINCO): 500–506.

Guerreiro, J., Lourenço A., Silva H., Fred A. 2014.

Performance Comparison of Low-cost Hardware

Platforms Targeting Physiological. Computing

Applications Conference on Electronics,

Telecommunications and Computers – CETC 2013

Procedia Technology 17: 399 – 406.

Laver, K., George, S., Thomas, S., et al. (2012). Cochrane

review: virtual reality for stroke rehabilitation. Eur J

Phys Rehabil Med, 48(3), 523–530.

Liedgens, H., Obradovic, M., De Courcy, J., Holbrook, T.,

& Jakubanis, R. (2016). A burden of illness study for

neuropathic pain in Europe. ClinicoEconomics and

outcomes research : CEOR, 8, 113-26.

doi:10.2147/CEOR.S81396

Mc Callum S. Gamification and Serious Games for

personalized health. PHealth 2012: Proceedings of the

9th International Conference on Wearable. B. Blober

et al (eds)

Massetti J. & Stein D.M., 2018. Spinal Cord Injury. White

J., Sheth K. (eds) Neurocritical Care for the Advanced

Practice Clinician. Springer, Cham.

Pozeg, P., Palluel, E., Ronchi, R., Solcà, M., Al-Khodairy,

A.-W., Jordan, X., … Blanke, O., 2017. Virtual reality

improves embodiment and neuropathic pain caused by

spinal cord injury. Neurology, 89(18), 1894–

1903.doi:10.1212/wnl.0000000000004585

Quaresma, C. et al., 2019. An Integrated System

Combining Virtual Reality with a Glove with

Biosensors for Neuropathic Pain: A Concept

Validation. In: Nunes I. (eds) Advances in Human

Factors and Systems Interaction. AHFE 2018.

Advances in Intelligent Systems and Computing, vol

781. Springer, Cham

Thrift, A. G., Thayabaranathan, T., Howard, G., Howard,

V. J., Rothwell, P. M., Feigin, V. L., … Cadilhac, D.

A.,2017. Global stroke statistics. International Journal

of Stroke, 12(1), 13–32.

https://doi.org/10.1177/1747493016676285

Villiger, M., Bohli, D., Kiper, D., Pyk, P., Spillmann, J.,

Meilick, B., … Eng, K.,2013. Virtual Reality–

Augmented Neurorehabilitation Improves Motor

Function And Reduces Neuropathic Pain In Patients

With Incomplete Spinal Cord Injury.

Neurorehabilitation And Neural Repair, 27(8), 675–

683.

Yannakakis, G.N. (2012) Games al Revised. In

Proceeding of ACM Computing Frontiers Conference.

2012: 285-292

BIODEVICES 2019 - 12th International Conference on Biomedical Electronics and Devices

290