Investigating immersive VR for People with MS and Upper Limb

• Research type

  Research Study

• Full title

  Upper Limb Rehabilitation using immersive Virtual Reality for people with Multiple Sclerosis; a feasibility trial

• IRAS ID

  311795

• Contact name

  Amy Webster

• Contact email

  Amy.Webster@gcu.ac.uk

• Sponsor organisation

  Glasgow Caledonian University

• Clinicaltrials.gov Identifier

  NCT05320237

• Duration of Study in the UK

  0 years, 8 months, 30 days

• Research summary

  Research Summary

  Virtual reality (VR) has reported benefits of engagement, immersion, and motivation in rehabilitation and has been proposed to be a solution for long-term engagement in rehabilitation. However, the use of VR within the multiple sclerosis (MS) population is not widely investigated and the optimal dose of therapy, such as frequency, time and intensity, especially regarding immersive VR that uses headsets remains unclear. The main aim of this study is to assess the feasibility of using the Oculus Quest VR headset and games for improving upper limb function within the MS population. In this study, we are looking to recruit participants with MS who have some self-reported upper limb dysfunction who will be randomly assignment to either an eight-week intervention using VR and upper limb exercise games, or the control group of usual care. Participants will be required to travel to Glasgow Caledonian University or NHS Lanarkshire (Coathill Hospital, Coatbridge) for the intervention and assessments. The VR intervention will use the Oculus Quest headset to play immersive VR games that have been designed by a co-production method, gathering data from people with MS and MS-specialists. After completion of the intervention, participants who undertook VR intervention will complete a survey regarding the usability of the games, and some individuals will be invited to interviews to express their experience of using VR and any suggestions for improvement for potential future trials. All participants will undertake testing at baseline, four weeks and eight weeks for multiple outcome measures of upper limb and motor function.

  Summary of Results

  Our aim with this study was we wanted to know how suitable and safe our virtual reality games were for people with multiple sclerosis (MS) for their upper limb (arms/hands) rehabilitation. This is the “feasibility” part of research. The results from this study will guide future, bigger trials. These will help us to understand if virtual reality and these games can improve upper limb mobility. But first we needed to know how practical this approach is for people with MS.
  Key Findings:
  • The virtual reality games were fun, enjoyable, and a distracting approach to exercise
  • Virtual reality is easy to learn and use, and safe in supervised sessions
  • Further studies need to focus on and increase recruitment

  Recruitment:
  Nineteen people were recruited, with eleven in the intervention group and eight in the control group. We aimed for thirty people with MS to take part but did not reach that goal. People we asked who said no often felt that the study would be “too much for them” or could not travel twice a week for the study.
  Multiple methods of recruitment were undertaken. We had help from NHS Lanarkshire, Revive MS Support, MS Society, and some people found out about the study online. To ensure there are more people with MS involved in future we will be more accommodating. Such as reducing the number of in-person sessions e.g. offering a home-based approach. We will also aim to have better communication with more NHS staff who could help us recruit.

  Attendance at Sessions:
  There was very good attendance for the virtual reality sessions and assessments from the control group. The most common reason for missing sessions were not feeling well or personal reasons. There were two people who dropped out of the study, both in the control group. Reasons were unrelated to the trial, with one being scheduling difficulties and the other reported having a suspected relapse.

  Control group acceptance
  Those randomised to the control group were overall accepting of this. Some even told us this was their preferred group. For reasons such as being unsure of virtual reality or not needing to travel as much for appointments.
  In future, we could offer a waiting list to those who want to take part in the rehabilitation after the study, so they can still get this opportunity. However, we are unsure how in demand this idea would be.

  How safe is immersive virtual reality?
  This study was investigating what is known as immersive virtual reality. Immersive virtual reality means the player wears a headset and feels like they are in the virtual games. It appears safe for people with MS, and no one reported any sickness while playing. There were some who reported some pain, discomfort or tiredness after sessions. The good news is that this was often mild, with good recovery.

  Upper limb tests
  For those in the intervention group, we observed a positive trend of improvement in the tests for both half way and after the eight weeks. Generally there were faster times for completion of the nine-hole peg test and increased hand grip strength. There was also better perceived upper limb ability and improved spasticity, as measured by the questionnaires.

  How does the intervention group compare to the control group?
  Interestingly, those in the control group also typically had improvements. They slightly improved their scores in the nine-hole peg test. But those in the intervention group appear to have better improvement, particularly in the non-dominant hand compared to those in the control. The improvements in hand grip strength also appear to be greater in the intervention group, compared to the control!
  It is worth noting however this is a small group of participants. Therefore, we need more participants in future studies to make sure of these changes. We’d need to confirm that virtual reality is causing these improvements, and it is not that people are just getting better at the tests.

  So are these tests suitable for future studies?
  Yes, we believe some are. However, there were some inconsistencies in the answers from the ABILHAND questionnaire, the questionnaire asking how easy or difficult it was to perform activities of daily living. Some answers given would say an activity was difficult at one assessment, but then also not performed within three months at another. A few people also highlighted that certain zips or bottle lids for example are easier than others. We could refine these instructions for future, making them much clearer.
  In the Action Research Arm Test, many participants had high scores in their first assessment. This made it difficult to assess changes over time. So it may not be the right test to use generally for people with MS. It is perhaps more suited to those with more severe upper limb dysfunction.
  Another great point that was raised by participants was how variable upper limb function can be day-to-day. So we would need make sure to keep the assessments as consistent as possible for those taking part. Such as taking the tests at the same time of day for people taking part.
  From participant feedback we would also like to make sure these tests are important to people with MS, and reflect everyday tasks better. To amend this, we aim to engage in more patient and public involvement to get a better understanding of what tests and improvements people with MS would like for future studies.

  Feedback: virtual reality games and study
  Overall, feedback was very positive. We also had really useful constructive suggestions for improvements. Some participants said they felt a benefit. Whether it was with mobility, confidence or just liking more exercise which was encouraging to hear.
  The games were described as fun, and the immersive virtual reality allowed participants to take their mind off things. The immersive virtual reality provided a distracting approach to exercise, and offered nice environments to be "immersed" in. Overall, participants found virtual reality was easy to use and learn how to use, but some did note it helped being supervised. However, we could make it clearer what specific hand movement are needed to play at first for the games, and make clearer menus.
  For each game:
  • Whack a mole game was a participant favourite. The gold moles that gave more points were highly motivating and people liked the full body aerobic workout for arms and core

  • Catch a falling star game was described frequently to have a great atmosphere. While it was good for arm movement, we could improve by making sure the stars are reachable every time

  • Piano game was the most divisive and challenging. While good for finger movement we need to make it more exciting and easy to play for varying abilities

  High scores in particular were very motivating for people too. But we need to ensure people are able to keep seeing progression. For example, adding difficulty levels and new games to keep people motivated long-term.

  There were some downsides to the virtual reality. This included the heaviness of the headset and technical issues with hand tracking. With how fast technology advances, we are optimistic this will improve. In terms of technical difficulties, direct sunlight stopped hand tracking and therefore we can make sure the room conditions are better in future.

  Future of this approach: Supervision versus Home?
  We are aware people with MS cannot always travel therefore we need to accommodate this. However, there were some participants who enjoying getting out the house and benefiting coming in, seeing people. The supervised appointments were also motivating for some. Hence, we need to make sure we can offer both in future. And we need to think about how we can offer this service to people with MS: through charity organisations or NHS?

  What’s next?
  We are really pleased virtual reality was overall found to be enjoyable.
  • We would like to add more games to the library that people with MS could access in future
  • We also wish to see if virtual reality games could be done at home for those who find travelling difficult
  • The next stage is to do a bigger study to see if virtual reality games do improve upper limb function and what the costs would be so that ultimately virtual reality interventions could be offered more widely to people with MS

• REC name

  West of Scotland REC 5

• REC reference

  22/WS/0049

• Date of REC Opinion

  27 Apr 2022

• REC opinion

  Favourable Opinion