Validity of a Virtual Environment for Stroke Rehabilitation

Judi A. Edmans, John R.F. Gladman, Sue Cobb, Alan Sunderland, Tony Pridmore,
Dave Hilton and Marion F. Walker
Stroke 2006;37;2770-2775; originally published online Sep 28, 2006;
DOI: 10.1161/01.STR.0000245133.50935.65
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 Validity of a Virtual Environment for Stroke Rehabilitation
Judi A. Edmans, DipCOT, MPhil, PhD; John R.F. Gladman, BSc, MBChB, DM, FRCP;
Sue Cobb, BSc, MSc, PhD; Alan Sunderland, BSc Hons, MPhil, PhD; Tony Pridmore, BSc, PhD;
Dave Hilton, BSc Hons, Cert Ed, MSc; Marion F. Walker, DipCOT, MPhil, PhD

Background and Purpose—Virtual environments for use in stroke rehabilitation are in development, but there has been
little evaluation of their suitability for this purpose. We evaluated a virtual environment developed for the rehabilitation
of the task of making a hot drink.
Methods—Fifty stroke patients undergoing rehabilitation in a UK hospital stroke unit were involved. The performance of
stroke rehabilitation patients when making a hot drink had the neurological impairments associated with performance
of this task, and the errors observed were compared for standardized task performance in the real world and in a virtual
environment. Neurological impairments were measured using standardized assessments. Errors in task performance
were assessed rating video recordings and classified into error types.
Results—Real-world and virtual environment performance scores were not strongly associated (␳⫽0.30; P⬍0.05).
Performance scores in both settings were associated with age, Barthel ADL score, Mini Mental State Examination score,
and tests of visuospatial function. Real-world performance only was associated with arm function and sequencing
ability. Virtual environment performance only was associated with language function and praxis. Participants made
different errors during task performance in the real world and in the virtual environment.
Conclusions—Although this virtual environment was usable by stroke rehabilitation patients, it posed a different
rehabilitation challenge from the task it was intended to simulate, and so it might not be as effective as intended as a
rehabilitation tool. Other virtual environments for stroke rehabilitation in development require similar evaluation.
(Stroke. 2006;37:2770-2775.)
Key Words: cerebrovascular disease 䡲 rehabilitation 䡲 virtual reality

T here is increasing research interest in the application of

virtual reality technology in psychotherapy,1 motor reha-
bilitation,2 and rehabilitation of people with intellectual
disabilities.3 Virtual environments have been used to support
learning of activities of daily living, including kitchen
skills,4,5 road crossing,6,7 catching a bus,8 shopping,9,10 and
social interaction.11
Virtual environments are potentially useful in stroke reha-
bilitation because they might be safer than attempting haz-
ardous tasks in the real world.12 They may also have
educational benefits; compared with the real world, virtual
environments can enable earlier rehabilitation because they
can be simpler, feedback can be more consistent or enhanced,
and some people find interaction with them enjoyable and
compelling. Virtual environments have the potential to en-
hance aspects of modern neuro-rehabilitation techniques;
virtual environments can potentially be more precisely con-
trolled than many real-world settings, intensive practice and
repetition of tasks can be easier, and progress can be recorded
automatically.
The very people who might require rehabilitation, such as
elderly stroke patients with multiple impairments, may find it
difficult to interact with, and benefit from, virtual environments.
However, demonstration projects show that virtual reality sys-
tems are acceptable to patients with stroke and traumatic brain
injury.13–18 They have been evaluated as assessment and thera-
peutic tools for cognitive ability or motor skills,19 but there been
only a few controlled studies.17,20
Even if patients with stroke can use such systems, little is
known about whether the neurological impairments that
affect the performance of a task in a virtual environment are
similar to those that affect real-world task performance,
whether mistakes made by patients in virtual and real world
are similar, and, hence, whether a virtual environment is a
suitable training environment. For example, visual neglect is
a common cause of problems in real-world functional tasks
after stroke and it is known that neglect can appear or
disappear depending on the exact cognitive requirements.21
Therefore, it needs to be established whether neglect would
appear in virtual environment so that training in that environ-

Received May 22, 2006; final revision received July 6, 2006; accepted August 11, 2006.
From Division of Rehabilitation & Ageing (J.A.E., J.R.F.G., M.F.W.), VIRART (S.C., D.H.), School of Psychology (A.S.), School of Computer
Science (T.P.), University of Nottingham, UK.
Correspondence to Dr Judi Edmans, Division of Rehabilitation and Ageing, B Floor, Medical School, Queens Medical Centre, Nottingham NG7 2UH.
E-mail judi.edmans@nottingham.ac.uk
© 2006 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000245133.50935.65

2770
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 Edmans et al Virtual Stroke Rehabilitation Environment 2771

Figure 1. Virtual environment display.

ment might have carry-over effects into the real world. Verbal memory: Story Recall from Rivermead Behavioral Mem-
Similar questions can be raised about other impairments seen ory Test (RBMT)27
Visuospatial function: Object Decision and Number Location
after stroke. subtests from Visual Object and Space Perception Battery (VOSP)28
Making a hot drink is commonly retrained during rehabil- Sequencing: Sequencing Pictures from Rivermead Perceptual
itation, normally requires repeated training in a real kitchen, Assessment Battery (RPAB)29
involves significant therapist time, and safety concerns pre- Attention: Tone Counting subtest from Test of Everyday Attention
(TEA)30
vent unsupervised practice. In the UK, many patients have
Praxis: Kimura Box31
limited training in hospital and go home unable to perform Arm function: 10-Hole Peg Test32
this basic task.15 On the basis that it was a useful application Motor function: Motricity Index33
of virtual environment training, we have developed a virtual Functional ability: Barthel ADL Index34
hot drink-making task. Hot drink-making in the real world was assessed as follows.
We investigated if stroke patients in rehabilitation were Participants were video-recorded making a hot drink in a rehabili-
able to interact with this virtual environment and assessed its tation kitchen according to a standardized protocol, using either or
both upper limbs, and under supervision by an occupational thera-
validity by testing the following 3 hypotheses: (1) there is a pist. The assessment schedule included 27 possible subtasks, of
correspondence between ability to make a hot drink in the which 12 subtasks were compulsory and 15 subtasks were optional.
real world and in the virtual environment; (2) the impairments There was no set order in which the subtasks had to be completed
affecting virtual and real-world task performance are similar; except for logistical or safety reasons (eg, water must be in the kettle
and (3) stroke rehabilitation patients make similar errors
when performing virtual and real-world tasks. TABLE 1. Recruitment of Participants
Reason not Recruited N (%), n⫽167
Materials and Methods Not suitable for rehabilitation 50 (30)
Participants were recruited from the Stroke Unit, Queens Medical
Centre, Nottingham, UK. Patients were suitable if they had a Rehabilitation complete: awaiting discharge ⫺12
diagnosis of stroke, were medically stable, undergoing rehabilitation, Medically unwell ⫺5
and had a goal of returning home. Patients with dementia, major No goal of returning home ⫺33
psychiatric illness, epilepsy triggered by screen images, those unable
to speak English or hear ordinary speech, with no upper limb Not suitable for virtual rehabilitation 42 (25)
function, and those enrolled in other studies were excluded. Dementia or psychiatric illness ⫺17
After written consent, demographic and basic stroke-related data Screen triggered epilepsy ⫺1
were collected, and participants were assessed using standardized
measures of cognitive and motor function, hot drink-making perfor- Prestroke deafness ⫺1
mance in the real world and in the virtual hot drink-making Not able to speak English before stroke ⫺7
environment. The assessments were performed over ⬎1 session and Poor visual acuity ⫺6
in the aforementioned order. The standardized assessments of cog-
nitive and motor function used were: No upper limb function ⫺2
Poor communication (insufficient to give consent) ⫺8
Language: Sheffield Aphasia Screening Test22
Global cognition: Mini-Mental State Examination23 Enrolled in other studies 2 (1)
Visual inattention: Star Cancellation24 Declined to give consent 23 (14)
Visuospatial function and memory: Rey Figure Copying and
Recruited 50 (30)
Recall25,26

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2772 Stroke November 2006

TABLE 2. Neurological Deficits at Baseline correctly. If the participant did not continue with the next subtask
within 20 seconds, there was an auditory prompt asking, “What
Variable Participants would you do now?” If the participant was unable to initiate the next
Impaired subtask, there was an auditory instruction of the next subtask (eg,
Domain Assessment Cutoff (%) “pour the boiled water from the kettle into the teapot”) and if the
Global cognition Mini Mental State Examination ⬍24 9/45 (20) participant remained unable to complete the subtask, the system
demonstrated the subtask on screen. Additional cues provided by the
Language Sheffield Aphasia Screening Test ⬍15 5/50 (10) system included a “ping” sound and an arrow above an object when
Neglect Star Cancellation ⬍51 26/50 (52) it was selected. Participants were taught how to operate the touch
Perception Rey Figure Copying ⬍30 38/49 (78)
screen interface in a practice virtual task involving putting a letter in
an envelope. A virtual hot drink-making score was calculated as in
VOSP Object Decision ⬍14 18/50 (36) the real-world assessment.
VOSP No. Location ⬍7 22/49 (45) Errors during task performance were assessed as follows. Participants
were video-recorded during real world and virtual environment task
Sequencing RPAB Sequencing Pictures ⬍2 22/50 (44)
performance. The video tapes were subsequently viewed to classify
Visual memory Rey Figure Recall ⬍14 37/41 (90) error types in task performance using a schedule based on published
Verbal memory RBMT Story Recall ⬍6 19/38 (50) literature and clinical experience comprising problems with initiation,
attention, neglect, addition, sequence omission, perseveration, selection,
Attention TEA Tone Counting ⬍7 22/48 (46) object use, problem solving, dexterity, quantity, and spatial awareness.
Praxis Kimura Box ⬎4 19/50 (38) Error analysis was undertaken on a sample of the paired video
recordings of 20 participants.

before the electricity is switched on). Videos were scored by trained
assessors. Each subtask was scored according to the level of
independence (ie, independent, required verbal assistance, or depen-
dent/required physical assistance). A total score was calculated,
being the ratio of the sum total of subtasks completed compared with
the number of subtasks that were attempted, and expressed as a
percentage.
The virtual environment was displayed and interacted with using
a laptop computer touch screen and handheld stylus. The required
components (eg, kettle, instant coffee) were displayed on the screen
(Figure 1). Participants had to tap the required object with the stylus
to select it and a second tap was required at the object’s destination
to trigger its animation. Immediate feedback was provided by an
auditory message saying whether each subtask had been performed
Results
Fifty participants were recruited between March 2004 and
May 2005 from the 167 stroke patients identified (Table 1).
The mean age of the participants was 69 years, 26 were men,
21 had a right and 29 had a left hemiparesis, 37 had anterior
circulation, 10 had lacunar strokes, and 3 had posterior
circulation strokes. Participants demonstrated a typical range
of stroke-related impairments (Table 2).
During the real-world task, 39 participants mainly used
their dominant hand (which was the paretic side in 29 of
these) and 11 relied on the nondominant hand. During
interaction with the virtual environment, 40 participants

Figure 2. Real and virtual world assess-

ment percentage scores.

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 Edmans et al Virtual Stroke Rehabilitation Environment 2773

TABLE 3. Correlations Between Clinical Variables and TABLE 4. Comparison of Error Types During Real-World and
Standardized Tests With Degree of Independence on Virtual Environment Task Performance (nⴝ20)
Real-World and Virtual Hot Drink-Making Performance
Error in
Real-World Kitchen Error in Both Real-World Error in Virtual
Assessment Score, VE Score, Assessment and Virtual Real-World Environment
␳ ␳ Error Type Environment Assessment Only Only
Clinical Variables Initiation 3 0 8
Age ⫺0.30* ⫺0.35* Attention 0 3 2
Days from stroke onset ⫺0.18 ⫺0.12 Neglect 0 1 1
Motricity Index (arms) 0.17 ⫺0.06 Addition 0 1 0
Barthel ADL Index 0.48‡ 0.40† Sequence 5 0 9
Cognitive Tests omission

Mini Mental State 0.46† 0.45‡ Perseveration 0 1 1

Examination Selection 0 1 9
Sheffield Aphasia Screening 0.08 0.40‡ Object use 0 0 0
Test Problem 2 0 6
Star Cancellation 0.44† 0.53‡ solving
Rey Figure Copying 0.49‡ 0.49‡ Dexterity 2 0 8
VOSP Object Decision 0.44† 0.35* Quantity 0 6 0
VOSP No. Location 0.46† 0.29* Spatial 0 1 0
RPAB Sequencing Pictures 0.51‡ 0.18
Rey Figure Recall 0.29 0.12
RBMT Story Recall 0.05 0.22 mistakes could only be made in the real world (such as
TEA Tone Counting 0.11 0.04 spilling water onto an electric cable), and certain mistakes
Kimura Box ⫺0.19 ⫺0.32*
were likely to be caused by interface problems (such as when
the user attempted to speak to the virtual environment
10-Hole Peg Test (time) ⫺0.47† ⫺0.17
expecting an answer, or when a stirring action of the stylus
*P⬍0.05; †P⬍0.01; ‡P⬍0.001. was interpreted as alternating selection and de-selection of an
object), or if there were technical problems (such as freezing
of the virtual environment program).
mainly used their dominant hand (paretic side in 29 cases)
and 10 used their nondominant hand.
Discussion
The scores for the real world and virtual environment tasks Our virtual environment was feasible for use in a stroke
were significantly but not strongly correlated (Spearman’s rehabilitation unit, performance of hot drink-making in the
␳⫽0.30; P⬍0.05). Real-world independence was greater: the real and virtual worlds were correlated, and the real-world
mean difference between real world and virtual environment tasks and virtual tasks were sensitive to similar stroke-related
scores was 7.9 (standard deviation, 11.3; range, ⫺9.5 to impairments. Taken alone, these findings would indicate that
38.6). A scatterplot (Figure 2) shows that many participants our virtual environment may be a useful rehabilitation tool for
scored maximally in the real-world kitchen assessment but patients undergoing stroke rehabilitation in hospital. How-
scored less than maximally in the virtual environment. ever, making a virtual hot drink was more difficult than
Validity was assessed in terms of whether similar factors making a hot drink in a rehabilitation kitchen, and it was
predicted performance in the real world and virtual environ- evident from the comparison of the video recordings that
ment (Table 3). Both real and virtual performance scores people with stroke made different mistakes when making a
correlated with age, Barthel ADL, Mini Mental State Exam- real and virtual hot drink. Therefore, despite appearing to
ination scores, and on tests of visuospatial perception. Real resemble each other, virtual and real hot drink-making are
world but not virtual environment performance was associ- qualitatively different tasks for stroke patients. The difference
ated with arm function and sequencing ability. Virtual envi- between real and virtual tasks has not previously been
ronment but not real-world performance was associated with examined in rehabilitation after brain injury.
language function and praxis. One explanation for the difference in difficulty between
There was little association between error patterns when real and virtual hot drink-making may simply be because
participants attempted to make a hot drink in the real world many of our participants were unfamiliar with computers,
and virtual environments (Table 4). The mean number of because we found that interface and technical problems
individual errors on real-world performance was 1.95 com- contributed to the difference between real and virtual perfor-
pared with 3.70 in the virtual environment (Wilcoxon Signed mance. In our extensive developmental work using a user-
Ranks test z⫽2.14; P⬍0.05). Some participants demonstrated centered design process,15 we had aimed to develop a system
errors suggestive of visual inattention in the real world but that was suitable for users of this type, and this had informed
not in the virtual environment, and vice versa. Certain our choice of a simple, nonimmersive system. However, we
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2774 Stroke November 2006
did not test it using an age- and education-matched control
group to explore this possibility. Another explanation for the
difference between the difficulty between real and our virtual
hot drink-making, supported by our findings, is that the
virtual task may be inherently more sensitive to stroke
deficits such as aphasia (each user has to be given instructions
of some sort) and dyspraxia (the user has to manipulate a
stylus). With either explanation, virtual and real-world hot
drink-making tasks are qualitatively different, and so training
one task may not lead to changes in performance in the other.
Further design work or alternative strategies using different
technologies might improve the similarity between real and
virtual tasks. One approach would be to use more sophisti-
cated immersive systems, using data gloves, hepatics, and
headset displays. Case studies have found positive acceptance
of these systems,13,17 although some users experienced diffi-
culty in using input devices to navigate around a virtual
environment.10 Another way around the problem of creating
a more naturalistic interface to a virtual environment that
requires the same body functions as the real world task is to
use “mixed reality” environments. In these, real objects are
manipulated to control their counterparts in the virtual envi-
ronment, instead of the un-naturalistic interface of the com-
puter touch screen. Such mixed reality environments should
still have the potential educational benefits of safety, ease of
use, consistency, controllability, repeatability, ease of moni-
toring, and motivation.12,35 They would also have a greater
potential to train motor skills and praxis.
Despite the fact that our virtual task was more difficult than
the real-world task, at least it simulated the task. Furthermore, by
our choice of hardware, our system was portable and therefore
flexible in use and inexpensive, making it easily replicable
elsewhere. Although further development is needed, our virtual
environment may nevertheless be a valuable rehabilitation tool
for some patients aiming at making a hot drink, because it
retains many of the potential educative benefits of the virtual
environment, such as the ability to practice the task repeat-
edly and in safety, and encouraging error-free learning. We
argue that it is important to test feasible systems in clinical
practice while being aware of the need to develop potentially
better ones, which themselves should be clinically evaluated
in due course.
Acknowledgment
We thank staff and patients on the Queen’s Medical Centre stroke
unit for accommodating this study, and Karen Newell and Shirley
Thomas for assistance in analyzing the virtual environment errors.
Sources of Funding
The Stroke Association funded this project.
Disclosures
None.
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