A spinal cord injury (SCI) impacts nearly every aspect of a person's life. People with
SCI will have muscular paralysis and loss of sensory and autonomic function below the
level of their injury. Immediately following injury, people with SCI require acute
in-patient care, during which rehabilitation is started. Following an SCI, people are at
risk of pressure ulcers, urinary tract infections, spasticity, autonomic dysreflexia,
depression, neuropathic pain, difficulty breathing, and circulatory problems. The
multitude of impairments following SCI are associated with lower quality of life.
Reducing reliance on care and achieving higher levels of independence is a major goal for
people with SCI. People with SCI can improve the motor power and therefore function of
their paralysed limbs through rehabilitation. This enables people with SCI to carry out
tasks which would otherwise require a carer. Dressing, bladder and bowel care,
transferring in and out of a wheelchair, and feeding are activities that often require
more assistance. The difficulty in carrying out these activities can be greatly reduced
if people with SCI can recover function in the upper limbs. Even small improvements in
limb function can have large effects on a people with SCI's independence.
For people with tetraplegia, where the injury affects all four limbs, improving upper
limb function is a major focus of rehabilitation. People with tetraplegia reported
improvement in hand and arm function as their highest priority for improvement compared
to other rehabilitation targets. Improvements in upper limb function can be achieved
through Activity-Based Therapy (ABT). ABT refers to any intervention that involves high
intensity, repetitive exercises which target activity-dependent plasticity in spinal
circuits. The improvements from ABT in upper limb function have greater effects on
quality of life when compared to traditional physical interventions targeted above the
level of injury. Exercise can alleviate symptoms of some secondary conditions which can
positively impact on quality of life. Physical inactivity is often reported by spinal
cord injured people, with limited access to exercise being just one of many barriers to
active lifestyles. There is a clear need to improve the accessibility of therapy for
people with SCI.
Virtual Reality (VR) technology used as an assistive device for upper limb rehabilitation
has good potential for people with SCI during rehabilitation by facilitating greater
adherence to therapy and increasing access to the most effective rehabilitation
strategies for people with neurological disorders. However, currently only a few studies
have investigated the use of VR in SCI rehabilitation of the upper limbs. Of these
studies, most have reported positive outcomes.
Three systematic reviews on the use of VR after spinal cord injury have been published in
the last few years. Overall the findings suggest that VR training can improve motor
function and balance, reduce symptoms such as pain, and improve aerobic function.
However, there were consistent limitations reported including a relatively small number
of studies, small experimental samples, and no consensus on the optimal treatment
parameters or technology employed. Furthermore, there were no studies that evaluated the
use of VR in the acute phase following SCI when there is most potential for recovery.
VR can have positive psychological effects among people with an SCI such as increased
self-confidence, motivation, and participation in therapy. ABT has been shown to improve
function through neuromuscular recovery and increase participation in therapy. The
principles of ABT which target motor improvement could be integrated into a VR
intervention for upper limb rehabilitation, which could provide a promising and exciting
option for people with SCI in early stages of recovery.
There are challenges in the delivery of ABT, such as the cost associated with using
assistive devices, resources required to train staff, difficulty achieving sufficient
dosage, factors such as motivation to engage in therapy, and access to therapy equipment.
These challenges could be overcome by collaborating with people with SCI and their carers
at the design stage of an intervention to impart valuable expertise about their chronic
conditions, experiences of the acute phase recovery immediately following injury, and
ideas about how to better manage rehabilitation. This intervention has been developed
using co-production, where end-users (people with SCI and SCI therapists) were involved
at every stage of the development process. This process can produce interventions that
are highly accepted and efficacious.
The investigators have therefore developed a set of VR-based physical exercises for upper
limb rehabilitation in collaboration with people with lived experience of tetraplegia and
spinal cord injury specialists. VR will allow the participant to repeatedly experience
engaging, fun, and motivating digital environments within which can be practised upper
limb movements as an adjunct to standard upper limb rehabilitation. The aim of this
randomised controlled feasibility study is to determine if this intervention is usable
and acceptable for people with tetraplegia and therapists during acute rehabilitation.