Is That the Arc de Triomphe Just Ahead?
Virtual Reality Places Physical Therapy Patients in Paris and Encourages Them to Keep Walking

Stories by Jim Raper

The School of Physical Therapy at Old Dominion University is teaming with the university’s Virginia Modeling, Analysis and Simulation Center (VMASC) to give walking-impaired stroke victims a virtual reality path to recovery.

A group of researchers led by Martha Walker, chair of physical therapy in ODU’s College of Health Sciences, has recorded an impressive success rate through the first 18 months of the project.

The rehabilitation strategy being employed was illustrated by the visit of a 62-year-old Portsmouth man to a Health Sciences Building lab in February of this year. He is the seventh client of the research project and he appropriates for himself the name Patient 007. But the fact is, he has some work to do before he is in “special agent” form. He has hardly walked at all since he was disabled by a stroke in 2007. He says he does not have confidence in his balance, but he has told the researchers that he knows he must rise from his wheelchair and practice getting around on his own two feet if he is to get his balance back.

Toward the end of the 90-minute visit, Patient 007 will take a treadmill walk in a make-believe environment displayed on a large-screen television and driven by computer software. “It’s more like you’re out for a stroll than on a treadmill,” Walker says. And it’s not a routine stroll. The virtual environment follows a sidewalk along a busy boulevard, and as patients walk they see on the horizon the Arc de Triomphe. Could this be the Champs Elysees? Are we in Paris? A virtual walking mate named Chris urges patients to keep going so they can get a close-up look at the celebrated Arc.

Virtual reality therapy plays to ODU’ s strengths
Virtual reality has long been used for military and pilot training. More recently researchers have been looking at ways to adapt the technology for rehabilitation uses. Some groups have developed programs to enhance hand function or ankle function. Walker and her team decided to work on the whole-body task of walking. The combination at ODU of rehabilitation professionals and techno-wizards, made this a perfect place to carry out this research. (See sidebar story for another virtual reality physical therapy application being tested at the College of Health Sciences.)

The School of Physical Therapy is known for its fully accredited and thorough program leading to a doctorate, as well as for the high rate of licensure of its students. The school moved during 2006 into state-of-the-art facilities in a remodeled Health Sciences Building. Furthermore, Walker wanted to take advantage of ODU’s VMASC, which specializes in simulation and visualization applications, such as one that teaches a medical student how to perform in a virtual operating room. Finally, Walker knew that she could tap working relationships already in place between her college and experts at the local Eastern Virginia Medical School and Sentara Norfolk General Hospital.

For startup funds, she turned to a multidisciplinary seed grant competition sponsored by the ODU Office of Research. She proposed a team of investigators including two colleagues from the College of Health Sciences, George Maihafer, associate professor of physical therapy, and Gianluca De Leo, assistant professor of medical laboratory and radiation sciences. Stacie Ringleb, a biomechanical engineer and VMASC researcher, and Jessica Crouch, an assistant professor of computer science, signed on as well, and so did Bonnie Van Lunen, assistant professor of exercise science, sport, physical education and recreation at ODU’s Darden College of Education. From outside of ODU, Walker recruited Jean Shelton, chair of the physical medicine and rehabilitation department at EVMS, as well as Robert Walker, attending physician for the stroke rehabilitation unit at Sentara Norfolk General Hospital.

The impressive lineup of investigators and the novel idea helped the project—which Walker dubbed “Virtual Reality in Gait Rehabilitation”—win $75,000 of the ODU seed money. The goal of the Office of Research is to fund startup research that can quickly evolve into projects that win external funding.

Project is successful right from the start
With the seed funding, the researchers began assembling their hardware: a personal computer, a 50-inch flat-screen television, a professional-grade treadmill and a harness-and-hoist device that can steady patients and, if necessary, support a little of their weight while they are gaining strength. Next came the software phase. Some of the simulation software could be purchased, but it had to be integrated into an overall program.

Early in 2007, Walker and Maihafer began to see patients. When Walker made the progress report that the Office of Research required in the summer of 2007, she told her audience that four patients had been seen, and that all four had made significant progress. She seemed amazed herself by the results. These patients were recovering stroke victims who for one reason or another had stopped making progress in their physical therapy, and yet were not walking as well as they wanted to. But put them on the Champs Elysees and, Voila! they walked and walked and walked, gaining strength with every visit to the lab.

Similar success was recorded for patients five and six in the second half of 2007. But Walker did not know what to expect from Patient 007, who arrived on that February 2008 morning in a wheelchair, attended by the two home nurses who look after him for most of the day at his apartment in Portsmouth. Patient 007, as was clear from the preliminary tests that Walker performed, was unsteady. His left leg seemed almost useless. “He is the most impaired patient we have had” in the project, Walker says.

Still, Patient 007 has a good attitude. He has a sly sense of humor and obviously enjoys trying out his lines on the half-dozen people in the lab. He was a cornerback and punt returner on the football team at the old Crestwood High School in Chesapeake, he says. He thinks if this therapy is successful he just may take up football again. But maybe that’s asking too much. At the least, he wants to be able to dance at his son’s wedding, which is only a few months off. And he really would like to be an usher again at his church.

Patient is skeptical at first
Walker’s goal for Patient 007 on this February morning is a five-minute walk in the virtual environment. She tells him this as she is putting him through the preliminary medical and dexterity tests. Without losing his ready smile, he shakes his head in skepticism. “I can’t even walk to my refrigerator when I’m hungry,” he quips. He looks over at the virtual reality pod in the corner of the lab and his eyes settle on the harness that will keep him steady as he walks. He says it looks like something the Marquis de Sade would invent.

Patient 007 felt the stroke coming on last year while he was driving to work at WalMart. He says his left leg started to feel heavy and he began to drool. He drove straight to a hospital, where he was helped onto a bed. The next thing he remembers, he wanted to get up but his body would not respond.

He tells Walker that he has gained confidence in his balance in recent weeks. But he warns her yet again not to expect too much walking from him. The time has come for his introduction to the treadmill, and he steps onto the machine only with a lot of help from Maihafer. The harness is strapped around him, and he turns to give his nurses a big grin. He says the harness isn’t so bad after all. He is asked to select an ODU baseball cap from a box of new ones in several colors, including pink. He has to wear a hat to hold the sensor that triggers an alarm if he looks away from the screen. The researchers want him to give himself over to his virtual environment, not look at his feet. Patient 007 tells Walker he’ll take a beige hat. “That pink one is just not me. You can keep the pink,” he says.

The treadmill starts at a slow roll. Although Patient 007 is walking only about a half-mile an hour, he seems awkward. His left leg can’t get with the rhythm. Chris, the virtual companion, is only a voice that comes from a side speaker. “Hi, I’m Chris. I’m here to walk with you around town.”

Slowly the speed increases and Patient 007 settles into a gait that pleases the researchers. He seems to get a second wind. The Arc de Triomphe appears in the distance and gets larger as he walks. “You’re doing well today,” Chris says. And a few moments later, “The more you walk, the stronger you’ll get.” Patient 007 wants to know how long he has been walking. Walker tells him three minutes. He wants to stop, but she encourages him to keep going for a little while longer. “Excellent, keep walking to the finish line,” Chris intones. “Take nice slow breaths. We can get there.” The Arc de Triomphe is only a block or two away.

“It’s for my own good.”
The feeble left leg starts acting up again just shy of the destination, and by the time Walker yells, “Five minutes!” Patient 007 is pooped. Nevertheless, when he sits back down in his wheelchair he is beaming like a kid who just returned a punt for a touchdown. “Terrific job. We work you hard, don’t we,” Walker says. “Yes, but I know it’s for my own good,” he replies.

This is just the start of Patient 007’s therapy. With each visit to the lab over the late winter and early spring, he will be encouraged to exercise for longer stretches of time on the treadmill. Walker is hopeful about his results.

This is just the start, too, of the overall research project. Walker believes the research will be sustained by additional funding, which will allow the team to conduct more tests of the concept. She wants to tweak the concept, too. What if there were a selection of virtual environments from which the patients could choose? “We could say, ‘Where would you like to go today?’ My favorite is a zoo,” she confesses. “The patient could make a virtual visit to a zoo.” Also, she would like to present graphics on the screen that are more lifelike.

But she steadfastly maintains that she wants neither the hardware nor the software to get too sophisticated or expensive. “The idea is for this to be inexpensive enough so every clinic can afford to have one of these systems,” she explains. Right now, the system in use, which is producing excellent results, can be had for under $10,000 if used with an existing treadmill and harness. A fancier setup with three-dimensional imagery or holographs could cost many times that, putting it out of reach for the average clinic to buy. “Our goal,” says Walker, “is to create a gait rehabilitation system that is effective and affordable so that all patients who need it can get the benefits.”

Added Maihafer, “So far the pilot study has demonstrated remarkable promise. I do hope, with proper funding, that we can broaden it.”

Walking Skills Grow for Children with Cerebral Palsy Who Play Dragon and Princess Game on Treadmill
Gait rehabilitation by means of a virtual reality stroll near the Arc de Triomphe is not the only research application of the television-and-treadmill pod in Old Dominion University’s College of Health Sciences.

Karen Kott, associate professor of physical therapy, and Gianluca De Leo, assistant professor of medical laboratory and radiation sciences, are testing game-based virtual reality as a way to improve the ambulatory capabilities of children with cerebral palsy. The children try to save a princess from a dragon as they walk—on the treadmill—in game environments that include forests, parks, towns and castles.

The researchers won a Summer Experience Enhanced Collaborative Research grant of $17,000 from the ODU Office of Research in 2007 to get the project off the ground. So far, collaboration between the College of Health Sciences, the ODU Center for Learning Technologies, and Virginia Modeling, Analysis and Simulation Center (VMASC) has produced a total of nine hours of simulated environments and background music that gives children a fun reason to walk on the treadmill.

As the children walk they can collect rewards for carrying out tasks that will help win freedom for the princess. Gems or coins are tacked to the special shirts the children wear, like medals being awarded for heroism.

A progress report completed after two boys, one 4 and the other 8, had completed the test regime, showed that the game environment did encourage faster and longer therapeutic workouts on the treadmill. Gross function motor tests are administered before the therapy starts and three weeks later when it is completed, and each boy displayed improvement in some test categories.

Kott said in early March that a third child had completed the regimen, also with positive results, and that other tests were planned. She and De Leo are discussing other funding possibilities with the Office of Research to extend and expand the project.

Assisting with the project have been Katrina Lester, a physician from the physical medicine and rehabilitation department at Eastern Virginia Medical School; physical therapy students Valerie Southerland, Nicole Ellis, Sherita Wilson and Shawn Rosengrant; and multimedia production staffers Brian Williamson, Stuart Gordon and Jacky Edwards.

Rosengrant presented a winning paper at the VMASC national Capstone Conference in April 2007 outlining the project objectives: 1) design and development of a virtual reality system to enhance treadmill training for interventions for children with cerebral palsy, 2) test the use of virtual reality as a motivational tool to enhance training on the treadmill in children with cerebral palsy, and 3) determine if there is any improvement in the participants’ functional ambulation using a Standardized Walking Obstacle Course.

“Incorporating game-based, virtual-reality treadmill training into the treatment of children with cerebral palsy is proposed to improve their ability to develop to their highest ability and may prove to have benefits that last throughout their lifetime,” the article stated.

Kott is an expert in the use of the Standardized Walking Obstacle Course for measuring ambulation in children. She said she expects to design future studies that will use virtual reality to test children with other disabilities and with other goals for the development of motor skills.

De Leo, who has a joint appointment to the College of Health Sciences and VMASC, has expertise in health and biomedical informatics and virtual reality.