NeuroRehabilitation 42 (2018) 441–448 441

DOI:10.3233/NRE-172361
IOS Press

Immersive virtual reality in traumatic

brain injury rehabilitation: A literature
review
Jared Aidaa,∗ , Brian Chaub and Justin Dunnc
a Department of Physical Medicine and Rehabilitation, Loma Linda University Health, Loma Linda, CA, USA
b Department of Veteran Affairs, Loma Linda Healthcare System, Department of Physical Medicine
and Rehabilitation, Redlands, CA, USA
c Loma Linda University School of Medicine, Loma Linda, CA, USA

Abstract.
BACKGROUND: Traumatic brain injury (TBI) is a common cause of morbidity and mortality in the United States with
its sequelae often affecting individuals long after the initial injury. Innovations in virtual reality (VR) technology may offer
potential therapy options in the recovery from such injuries. However, there is currently no consensus regarding the efficacy
of VR in the setting of TBI rehabilitation.
OBJECTIVE: The aim of this review is to evaluate and summarize the current literature regarding immersive VR in the
rehabilitation of those with TBI.
METHODS: A comprehensive literature search was conducted utilizing PubMed, Google Scholar, and the Cochrane Review
using the search terms “virtual reality,” “traumatic brain injury,” “brain injury,” and “immersive.”
RESULTS: A total of 11 studies were evaluated. These were primarily of low-level evidence, with the exception of two
randomized, controlled trials. 10 of 11 studies demonstrated improvement with VR therapy. VR was most frequently used to
address gait or cognitive deficits.
CONCLUSIONS: While the current literature generally offers support for the use of VR in TBI recovery, there is a paucity
of strong evidence to support its widespread use. The increasing availability of immersive VR technology offers the potential
for engaging therapy in TBI rehabilitation, but its utility remains uncertain given the limited studies available at this time.

Keywords: Virtual reality, traumatic brain injury, therapy, rehabilitation

1. Introduction of brain injuries may adversely impact an individ-

ual through effects on cognition, vision, mobility,
Traumatic brain injury (TBI) is a serious cause and mental health, leading to significant functional
of morbidity and mortality in the United States. In impairment (CDC, 2015). Rehabilitation for patients
one year alone, it was estimated that TBI led to recovering from a TBI can pose a difficult challenge
over 2.5 million emergency department visits, hos- for clinicians. There is greater public awareness of
pitalizations, and deaths (CDC, 2015). Such kinds TBI primarily from recent attention to head trauma in
sports (McKee et al., 2009). Additionally, recent mil-
∗ Address for correspondence: Jared Aida, Department of Phys-
itary conflicts overseas have also increased national
ical Medicine and Rehabilitation, Loma Linda University Health,
11406 Loma Linda Drive, Suite 516, Loma Linda, CA 92354,
attention to TBI, with the injury being described as
USA. Tel.: +1 909 558 6202; Fax: +1 909 558 6110; E-mail: the “signature injury” of wars in Afghanistan and Iraq
[email protected]. (Sessoms, 2015).

1053-8135/18/$35.00 © 2018 – IOS Press and the authors. All rights reserved
442 J. Aida et al. / Immersive virtual reality

Virtual reality (VR) traditionally involves the use sive VR in cognitive training, but since the study did
of immersive, three-dimensional environments, dis- not directly evaluate VR in the setting of TBI, it was
played to the viewer through a head-mounted display excluded from review.
(HMD) or a custom room with large screen walls.
User input, through controllers or body movements,
is translated into movements in the virtual setting. 3. Results
VR offers the potential for performing customiz-
able, engaging rehabilitation activities in a controlled There were 11 studies selected that were relevant
environment (Schultheis & Rizzo, 2001; Ferrer- to the aim of this review. Most of the studies were
Garcia et al., 2013; Parsons et al., 2009). Previously, of low-level evidence including three case studies
much of this technology was relatively unfeasible and five uncontrolled experimental studies. There
for widespread clinical adoption due to significant were two randomized, controlled trials and one relia-
financial barriers. However, current developments in bility study. All studies investigated immersive VR
VR technology from the entertainment industry have use in persons with some degree of TBI (mild,
greatly decreased the cost of such systems (Ferrer- moderate, severe). Of note, one study recruited partic-
Garcia et al., 2013; Parsons et al., 2009). Graphics ipants with TBI and/or PTSD (Highland et al., 2015).
display in high-definition (HD) resolution, motion Table 1 outlines a summary of all eleven studies
tracking, and interactive environments are now fairly reviewed.
standard features for the latest consumer-grade VR Christiansen et al. (1998) performed one of the first
devices. studies using VR with TBI patients in a rehabilita-
VR has been used in a variety of medical capacities tion setting. 30 subjects (aged 19 to 48) with severe
including pain management, phobia treatment, med- TBI, designated by initial GCS scores, were asked to
ical education, prosthetic training, and more. (Darter complete various meal preparation tasks in a virtual
& Wilken, 2011; Kaufman et al., 2014; Ortiz-Catalan kitchen. Each participant wore a headset, which pro-
et al., 2014; Dunn et al., 2017; Bouchard et al., 2017; jected the virtual environment, and used a computer
Morina et al., 2015; Hashimoto et al., 2017). This mouse to direct and complete 30 meal preparation
technology has also been utilized within the rehabil- tasks required to prepare a can of soup. Each task was
itation field, most notably in stroke therapy. Recent scored on a six-point scale, with a score of 6 indicat-
clinical practice guidelines for adult stroke rehabilita- ing a correct response, and a score of 1 indicating
tion include recommendations for VR use in treating the inability to complete the task after five attempts.
deficits of spatial, visual, verbal, mobility, and upper After two failed attempts, various cues (visual and
limb impairment (Winstein et al., 2016). No current verbal) were provided to assist in task completion.
recommendations are available regarding the use of Subjects underwent initial testing with repeat testing
VR for those with TBI. The aim of this review is to 7–10 days later. The intraclass correlation coefficient
evaluate and summarize the current literature regard- (ICC) model was used to assess test-retest reliabil-
ing the use of immersive VR in treating individuals ity. The mean total score of the first test was 156.37
with TBI. (SD = 14.33), and the mean total score for the retest
was 161.00 (SD = 13.02). The ICC value for the VR
total score was 0.73, indicating good reliability. Fur-
2. Method ther analysis revealed that three of the tasks required
increased variability in order to obtain better reliabil-
A comprehensive literature search was conducted ity. When these three tasks were eliminated from data
utilizing PubMed, Google Scholar, and the Cochrane analysis, the ICC improved to 0.81. The authors noted
Review. Search terms used included “virtual reality,” that all subjects tolerated the VR environment well
“traumatic brain injury,” “brain injury,” and “immer- with no vestibulo-ocular side effects (Christiansen
sive.” The references of all selected studies were et al., 1998).
reviewed to search for additional studies not found in Larson et al. (2011) evaluated the effect of hap-
the initial search. Studies that did not utilize immer- tic cueing in an immersive VR environment and its
sive VR were excluded from review, as many studies effect on attention in brain injured patients (Ran-
often incorrectly label all forms of therapy utilizing cho level IV-V). The VR system used in the study
electronic screens as virtual reality. One study (Lo was the Virtual Reality and Robotic Optical Opera-
Priore et al., 2003) examined the efficacy of immer- tions Machine (VRROOM), which allowed users to
 Table 1
Summary of studies involving immersive virtual reality in the setting of TBI rehabilitation
Study Type of Study Participants Intervention Outcome Measures Results
Christiansen Reliability Severe TBI (GCS ≤ 8) Completion of 30 meal preparation tasks Six-point scale (6 = correct response, Good reliability between test-retest with ICC
et al., 1998 Study N = 30 required to prepare a can of soup in a 1 = inability to complete task after five of 0.73
virtual kitchen attempts) ICC improved to 0.81 when three tasks
Participants underwent the initial test with Intraclass correlation coefficient (ICC) without adequate variance were eliminated
retest within 7–10 days
Larson et al., Experimental TBI with Rancho Target acquisition during six 4-minute Number of targets reached Significant improvement in target acquisition
2011 Uncon- Level IV-V N = 15 sessions in VRROOM system, on two from first day to second day
trolled Trial consecutive days Haptic nudge group significantly more
(Crossover Participants underwent 2 sessions under effective than repulsive cueing
Design) various haptic conditions: no haptic cue, Improvement in target acquisition time in
repulsive haptic force, and guiding patients with post-traumatic amnesia
haptic cue
Dvorkin et al., Experimental Severe TBI (Rancho Six 4-minute sessions in VRROOM Number of targets reached Significant improvement in target acquisition
2013 uncontrolled Levels of IV-V) system, on two consecutive days from first day to second day
trial N = 18 Participants underwent 2 sessions under Guiding haptic cues were significantly more
(Crossover various haptic conditions: no haptic cue, effective than repulsive cueing
Design) repulsive haptic force, and guiding
haptic cue
Biffi et al., 2015 Pilot, Children with ABI Five 30-minute sessions, twice a week, for Walking ability as measured by means Reduced step-by-step variation
uncontrolled and mild motor 3 weeks in the GRAIL system and standard deviations of Kinematic data of participants, especially at
study impairment Each session required participants to spatio-temporal, kinematic, and kinetic the ankle, became comparable to healthy
(GMFCS Level I-II) complete exercises requiring changes in data subjects
N=4 posture and balance
Biffi et al., 2017 Pilot, Children with ABI Ten 30-minute sessions, four times a week, Gross Motor Function Measure (GMFM) Improvement in GMFM gross motor capacity
uncontrolled and mild motor for 3 weeks in the GRAIL system Functional Assessment Questionnaire (p = 0.008), 6minWT (p = 0.002), and FAQ
study impairment Each session required participants to (FAQ) 6-Minute Walk Test (6minWT) (p = 0.025)
J. Aida et al. / Immersive virtual reality

(GMFCS Level I-II) complete exercises requiring changes in 3D-Gait Analysis: over ground (OGA), Increased gait symmetry per GGI (p = 0.043)
N = 12 posture and balance Grail (GGA)
Gamito et al., Case Study Severe TBI (GCS ≤ 8) 10 online VR sessions Paced Auditory Serial Addition Task Percentage of correct responses improved
2011 N=1 (PASAT) was administered for pre-, from pre to intermediate (p < 0.05), as well
during, and post-treatment assessment as intermediate to post (p < 0.05)
Rabago and Case Study Mild TBI CAREN Immersive Environment: six Postural and Gait Balance Significant improvements in postural and gait
Wilken, 2011 N=1 one-hour sessions over three weeks Post-concussion symptom score balance
Post-concussion symptom score: 41 at
baseline, 1 at completion
Gottshall and Case Study Mild TBI Vestibular physical therapy: 2 times per Dizziness Handicap Inventory (DHI) DHI: 18% disability at baseline, 0% at 6 weeks
Sessoms, N=1 week for 2 months Activities-Specific Balance Confidence ABC: 75.5% balance confidence at baseline,
2015 CAREN Immersive Environment: one Scale (ABC) 85% at 6 weeks
45-minute session per week for 6 weeks Computerized Dynamic Posturography SOT: 60% balance confidence at baseline, 84%
Sensory Organization Test (SOT) at 6 weeks
Functional Gait Assessment (FGA) FGA: 16/30 at baseline, 30/30 at 6 weeks
(Continued)
443
 444
Table 1
(Continued)
Study Type of Study Participants Intervention Outcome Measures Results
Sessoms et al., Randomized Mild TBI All Experimental Participants: 12 Self-selected walking speed Self-selected walking speed: Group 2
2015 Controlled N = 24 therapy sessions over 6 weeks Performance Scores on weight statistically similar to the control group by
Trial Randomized to Group 1 : 6 sessions with traditional shifting-controlled, boat-steering task week 2, Group 1 statistically similar to the
Group 1 or vestibulo-ocular physical therapy + 6 control group by week 4
Group 2 sessions with the CAREN Boat-Steering Performance: Neither group
Control for vestibulo-ocular training progressed to the same performance as the
Walking Speed Group 2 : 12 sessions with the CAREN control group; Statistically significant
N = 20 vestibulo-ocular training improvement for Group 2 vs Group 1 by week
Control for boat 2
score
N=7
Cox et al., 2010 Feasibility TBI VRDSRT Group (N = 6) received 4 to 6 Driving performance evaluated VRDSRT group: significant improvements in 5
study with N = 11 60- to 90-minute virtual training out of the 7 performance variables; significant
Randomized sessions in addition to intensive improvement in the the composite
Controlled inpatient rehabilitation performance score
Trial Design Control Group (N = 5) received intensive Control group: no statistically significant
inpatient rehabilitation only improvements in any performance variable.
Highland et al., Experimental N = 148 CAREN Immersive Environment: two CAREN presence questionnaire to Motion sickness vs Presence: those with motion
2015 Uncon- 95% TBI, 58% 30–50 minute sessions each quantify perceived immersion. The sickness reported lower presence (p = 0.01)
trolled PTSD mean scores were compared for Eye Discomfort vs Presence: those with eye
Trial patients that did/did not report motion discomfort reported lower presence (p = 0.01)
sickness and eye discomfort, for Motion sickness vs Responsiveness: those with
patients with varying degrees of TBI motion sickness reported lower
severity, and for patients with and responsiveness (p = 0.03)
without PTSD. Motion sickness vs Controllability: those with
J. Aida et al. / Immersive virtual reality

A Chi-Square analysis was performed to motion sickness reported lower controllability

determine if self-reported symptoms (p = 0.02)
varied according to TBI severity or PTSD vs Presence: those with PTSD reported
PTSD diagnosis. higher presence (p = 0.04). No statistical
difference in follow-up tests.
TBI severity vs Presence: No statistical
difference (p = 0.90)
Motion Sickness vs PTSD Diagnosis: No
statistical variation (p = 0.22)
Motion Sickness vs TBI Severity: No statistical
variation (p = 0.10)
Eye discomfort vs PTSD Diagnosis: No
statistical variation (p = 0.61)
Eye discomfort vs TBI Severity: No statistical
variation (p = 0.95)
 J. Aida et al. / Immersive virtual reality 445

view virtual targets superimposed onto a virtual land- mild motor impairment, as defined by Gross Motor
scape. Each participant was asked to reach towards Function Classification System (GMFCS) Level I and
as many targets as possible in an allotted time. Par- II, underwent five 30-minute sessions on GRAIL,
ticipants completed six blocks of trials, each lasting twice a week, for a total of 3 weeks. Treatments
4 minutes, on two consecutive days. Each participant included exercises in the VR environment, which
completed two trials under each haptic condition: no would require changes in posture and balance. At
haptic force; a repulsive force, similar to popping the end of the study, all participants trended towards
a balloon; and a brief, gentle guiding nudge in the normal walking patterns with reduced step-by-step
event of attention loss. Of the 18 patients enrolled, variability. Improvements were notable particularly
3 were unable to complete the experiment due to at the ankle (Biffi et al., 2015).
frustration, fatigue, and eye pain. Of the 15 patients Building on their previous research, Biffi et al.
who completed the experiment, there was signifi- (2017) expanded their pilot study with the GRAIL
cant improvement in target acquisition time from the system to further evaluate improvements in walking
first day to the second day. The haptic nudge group ability in the pediatric population. 12 children (mean
was a significantly more effective haptic cue than the age 12.1 years old) with ABI and mild motor impair-
repulsive cue. In addition, patients in post-traumatic ment (GMFCS Level I-II) underwent ten 30-minute
amnesia also had improvement in target acquisition treatment sessions on GRAIL, 4 times a week, for a
time (Larson et al., 2011). total of 3 weeks. Functional parameters were mea-
Dvorkin et al. (2013) expanded the work of Lar- sured before and after the VR treatments, including
son et al. (2011) by reproducing the same experiment Gross Motor Function Measures (GMFM), Gillette
with a larger sample size. 21 severely impaired TBI Functional Assessment Questionnaire (FAQ), the
inpatients (Rancho levels of IV-V) were recruited and 6-minute Walk Test (6minWT), and 3D-Gait Anal-
underwent testing in the VRROOM. Targets could be ysis over ground (OGA) and on GRAIL (GGA).
both seen via headset and felt via robotics rendering Spatio-temporal and kinematic data was similarly
haptic sensation. Once again, participants completed collected for both OGA and GGA, with a Gillette Gait
two 4-minute sessions, on two consecutive days, Index (GGI) calculated to summarize the degree of
under each haptic condition: no haptic cue, a repulsive gait deviation compared to normal walking pattern.
haptic force, and a guiding haptic cue. Participants All patients successfully completed the treatments,
were asked to reach towards as many targets as possi- showing statistically significant improvement in total
ble in each 4-minute session. Most patients were able gross motor function, endurance, and autonomy in
to tolerate the visuo-haptic environment, but three daily life activities. 3D-gait analysis also showed a
of the 21 patients were unable to complete the test significant decrease in the GGI and improvement in
due to fatigue or frustration. Of the 18 patients who general gait symmetry. The authors emphasized that
completed the study, there was a clear improvement the VR environment enhanced patient engagement,
in performance from the first day to the second day. particularly considering its pediatric population (Biffi
Compared to no haptic cues, guiding haptic nudges et al., 2017).
benefited patients more than repulsive haptic forces. Gamito et al. (2011) utilized online VR sessions
Of note, patients exhibited attention loss both before to assess improvement in memory and attention.
movement initiation and during movements (Dvorkin In this case study, a 20-year-old male with severe
et al., 2013). TBI (GCS ≤ 8) and resultant memory and attention
Biffi et al. (2015) set up a pilot study analyzing the deficits underwent 10 online VR sessions. The partic-
efficacy of utilizing a GRAIL (Gait Real-time Analy- ipant interacted with the VR environment through a
sis Interactive Lab) system to improve gait mechanics head mounted display and could move through the
in a pediatric population with acquired brain injury VR world by clicking a computer mouse; various
(ABI). GRAIL utilizes large, room-sized immersive tasks could be accomplished by simple keystrokes
screens combined with a treadmill-like platform, on a keyboard. The tasks in each session included
which obtains various spatio-temporal, kinematic, completing ADLs, navigating transit routes, and
and kinetic measures in real-time. Participants were completing simple cognitive tests. The subject was
required to stand or walk on an instrumented, force- assessed three times: pre-treatment, during treatment
plate treadmill in front of a large 180◦ projection (after session 5), and post-treatment. The assess-
screen during treatment sessions. 4 children (mean ment was the Paced Auditory Serial Addition Task
age 13.7 years old) with acquired brain injury and (PASAT), which has been used to assess working
446 J. Aida et al. / Immersive virtual reality

memory and attention. There was statistically signif- line to 0% by week 6, the ABC improved from
icant improvement in working memory and attention 75.5% balance confidence at baseline to 85% by
when comparing PASAT pre-treatment scores and 6 weeks, The SOT improved from 60% balance
post-treatment scores. This study also highlighted confidence at baseline to 84% by 6 weeks, and
the plausibility of telerehabilitation, and its ability the FGA improved from a score of 16/30 at base-
to improve cognitive function (Gamito et al., 2011). line to a score of 30/30 by 6 weeks (Gottshall &
Rabago and Wilken (2011) utilized a computer- Sessoms, 2015).
assisted rehabilitation environment (CAREN) in the Sessoms et al. (2015) expanded upon the protocol
rehabilitation of a 31-year-old male military service of Gottshall and Sessoms (2015) with a randomized,
member with mild TBI. The CAREN system is an controlled trial. This further evaluated the use of the
immersive environment in which a harnessed par- CAREN training system in 26 military participants
ticipant’s movements are recorded by force plates between the ages of 20 and 42 who had prior his-
measuring the shifting and motion of their weight tory of vestibular disorders related to a mild TBI
and projected onto the 180-degree screen display- in the previous year. Separate control groups were
ing a virtual environment. Kinematic and kinetic formed from uninjured active-duty military members
data was collected by a motion capture system. The for the walking speed task (n = 20) and for the boat-
patient participated in six one-hour sessions over steering task (n = 7). All 26 experimental participants
three weeks. The tasks in the CAREN environment were enrolled in a 6-week, 12-session program. Half
ranged from postural balance exercises to treadmill of the participants were randomly assigned to per-
walking and weapon handling to simulate active com- form six of their therapy sessions using traditional
bat duties. Initially in the treatment, the participant vestibulo-ocular therapy and six of their therapy ses-
reported exacerbation of concussion symptoms dur- sions using the CAREN (Group 1), whereas the other
ing the CAREN training. However, by the third day, half were assigned to use the CAREN for all 12
he no longer experienced symptom exacerbation due of their therapy sessions (Group 2). Outcome mea-
to the VR training. By the end of rehabilitation, the surements included self-selected walking speed on
patient’s post-concussion symptom scale score had the CAREN treadmill and a performance score on a
decreased from a score of 41 to a score of 1. Sig- boat-steering task, which was performed by the par-
nificant improvements in postural and gait balance ticipants shifting their weights on the CAREN force
were also noted following completion of the study. plates, which then determined the speed and direction
In addition, the patient experienced improvements in of the boat’s movements on the projection. Two par-
static and dynamic balance as well as improvements ticipants were excluded from the final analysis. At
in executive function and dual-task testing following baseline, both experimental groups had statistically
training with the CAREN environment (Rabago & similar walking speeds to each other, and both had sta-
Wilken, 2011). tistically significant, slower walking speeds than the
Gottshall and Sessoms (2015) utilized vestibular control group. Group 2 achieved statistically similar
physical therapy in the CAREN system to treat a walking speeds to the control group by week 2, and
41-year-old male with mild TBI following a motor- Group 1 achieved statistically similar walking speeds
cycle accident. The participant was initially involved to the control group by week 4. At baseline, both
in vestibular physical therapy twice per week for experimental groups had statistically similar boat-
two months. This therapy involved treadmill walk- steering performance scores to each other, and both
ing, balance exercises, eye and head movements, had statistically lower boat-steering scores than the
and somatosensory training. Following this, the par- control group. Neither group progressed to the same
ticipant began vestibulo-ocular and gait training in performance as the control group, but it was noted
the CAREN system, with one 45-minute session per that Group 2 progressed faster than Group 1 in per-
week for six weeks. The primary outcome measure- formance, with a statistically significant difference
ments utilized in this study included the Dizziness between Groups 1 and 2 evident by week 2 (Sessoms
Handicap Inventory (DHI), the Activities-Specific et al., 2015).
Balance Confidence Scale (ABC), the Computerized Highland et al. (2015) evaluated the immersive
Dynamic Posturography Sensory Organization Test presence and adverse effects associated with the
(SOT), and the Functional Gait Assessment (FGA). use of the CAREN training system in 148 military
The DHI improved from 18% disability at base- service members (SMs) using a presence question-
 J. Aida et al. / Immersive virtual reality 447

naire derived from the Witmer and Singer Presence VR to treat gait and balance deficits (5 articles), as
Questionnaire. They found that the participants who well as cognitive deficits (4 articles), both frequently
experienced motion sickness were more likely to also encountered challenges in TBI rehabilitation. Two
report a lower immersive presence and controllabil- studies included the use of control groups, and sev-
ity in the CAREN environment than the participants eral studies had 20 or more participants. Adverse
who did not experience motion sickness. Addition- effects were limited as VR was overall well toler-
ally, they found that participants with PTSD reported ated, but did include motion sickness, frustration,
a statistically high immersive presence than those fatigue, and eye discomfort. Motion sickness was
without PTSD. They also found that immersive pres- the most commonly reported and limiting adverse
ence, motion sickness, and eye discomfort did not effect with VR, so caution should be exercised with
vary with varying TBI severity among participants individuals who have a history of motion sickness.
(Highland et al., 2015). Numerous studies also emphasized improved compli-
Cox et al. (2010) utilized a controlled trial design ance and motivation in participants when using VR,
of a VR driving simulator in the rehabilitation of particularly in the pediatric population. Early rep-
patients with one or more closed head injuries who etition of skilled, task-directed actions remains a
were participating in a 12-hour per day rehabilitation mainstay of neurologic rehabilitation therapy, and
program. Six participants were randomly assigned the use of VR may improve compliance due to its
into the virtual reality driving simulation rehabilita- ability to make therapy sessions more enjoyable.
tion training (VRDSRT) group and five participants The increasing availability, low cost, and safety of
were assigned to the control group. The participants VR systems further reinforces the use of VR in the
in the VRDSRT group received four to six, 60- to 90- setting of TBI rehabilitation. However, despite the
minute virtual training sessions between the pre- and predominately beneficial effects of VR noted, the
post-assessments. Each subject participated in a driv- quality of evidence of current literature remains low.
ing simulator before and after rehabilitation, with the Most of the studies consisted of case reports and
simulation administered by a researcher blinded to non-randomized trials without controls. The rehabil-
the patients’ group assignments. In addition to evalua- itation protocols used varied greatly, although several
tion of driving behavior in the simulation, participants studies did attempt to build upon prior work by
completed the Road Rage Questionnaire and the Cox using identical VR environments (VRROOM and
Assessment of Risky Driving Scale (CARDS) in GRAIL).
order to evaluate simulation performance. Follow-
ing completion of the study, it was shown that the
VRDSRT group improved in every outcome mea- 5. Conclusion
sure, with significant improvements in 5 out of the
7 performance variables, whereas the control group Overall, while generally supportive, only very lim-
demonstrated no statistically significant improve- ited evidence is available to support the use of VR in
ments in any performance variable. In addition, the TBI recovery. As a rehabilitation modality, VR has
VRDSRT group had a significant improvement in the potential to provide significant therapy options
the composite performance score, whereas the con- for the TBI population, yet remains to be fully inves-
trol group had no significant improvement (Cox tigated at this time.
et al., 2010).

Acknowledgments
4. Discussion
We would like to thank the Loma Linda Univer-
Our aim with this review was to evaluate the cur- sity Health Department of Physical Medicine and
rently available published data on the use of VR for Rehabilitation for their support.
the TBI population. Of the 11 studies and reports
reviewed, 10 noted positive outcomes with using
VR. The one remaining study was a reliability study Conflict of interest
that affirmed excellent stability of performance using
VR. A common theme of these studies was using There are no conflicts of interest to report.
448 J. Aida et al. / Immersive virtual reality

References tual reality endoscopy curriculum improves performance

on the fundamentals of endoscopic surgery examination.
Surgical Endoscopy. Retrieved from https://link.springer.
Biffi, E., Beretta, E., Cesareo, A., Maghini, C., Turconi, A.C., Reni,
com/article/10.1007%2Fs00464-017-5821-5
G., & Strazzer, S. (2017). An immersive virtual reality plat-
Highland, K.B., Kruger, S.E., & Roy, M.J. (2015). If you build it,
form to enhance walking ability of children with acquired brain
they will come, but what will wounded warriors experience?
injuries. Methods of Information in Medicine, 56(2), 119-126.
Presence in the CAREN. Studies in Health Technology and
Biffi, E., Beretta, E., Diella, E., Panzeri, D., Maghini, C., Turconi,
Informatics, 219, 23-27.
A.C., Strazzer, S., & Reni, G. (2015). Gait rehabilitation with
Kaufman, K.R., Wyatt, M.P., Sessoms, P.H., & Grabiner,
a high tech platform based on virtual reality conveys improve-
M.D. (2014). Task-specific fall prevention training is effec-
ments in walking ability of children suffering from acquired
tive for warfighters with transtibial amputations. Clinical
brain injury. Conference proceedings: Annual International
Orthopaedics and Related Research, 472(10), 3076-3084.
Conference of the IEEE Engineering in Medicine and Biology
Lo Priore, C., Castelnuovo, G., Liccione, D., & Liccione, D. Expe-
Society, 7406-7409.
rience with V-STORE: Considerations on presence in virtual
Bouchard, S., Dumoulin, S., Robillard, G., Guitard, T., Klinger, E.,
environments for effective neuropsychological rehabilitation
Forget, H., Loranger, C., & Roucaut, F.X. (2017). Virtual real-
of executive functions. Cyberpsychology & Behavior, 6(3),
ity compared with in vivo exposure in the treatment of social
281-287.
anxiety disorder: A three-arm randomised controlled trial. The
McKee, A.C., Cantu, R.C., Nowinski, C.J., Hedley-Whyte, E.T.,
British Journal of Psychiatry, 210(4), 276-283.
Gavett, B.E., Budson, A.E., Santini, V.E., Lee, H.S., Kubilus,
Centers for Disease Control and Prevention. (2015). Report to
C.A., & Stern, R.A. (2009). Chronic traumatic encephalopa-
Congress on Traumatic Brain Injury in the United States:
thy in athletes: Progressive tauopathy after repetitive head
Epidemiology and Rehabilitation. National Center for Injury
injury. Journal of Neuropathology and Experimental Neurol-
Prevention and Control; Division of Unintentional Injury Pre-
ogy, 68(7), 703-735.
vention. Atlanta, G.A.
Morina, N., Ijntema, H., Meyerbroker, K., & Emmelkamp, P.M.
Christiansen, C., Abreu, B., Ottenbacher, K., Huffman, K., &
(2015). Can virtual reality exposure therapy gains be gen-
Masel, B., Culpepper, R. (1998). Task performance in virtual
eralized to real-life? A meta-analysis of studies applying
environments used for cognitive rehabilitation after traumatic
behavioral assessments. Behavior Research and Therapy, 74,
brain injury. Archives of Physical Medicine and Rehabilitation,
18-24.
79(8), 888-892.
Ortiz-Catalan, M., Sander, N., Kristoffersen, M.B., Hakansson,
Cox, D.J., Davis, M., Singh, H., Barbour, B., Nidiffer, F.D., Trudel,
B., & Branemark, R. (2014). Treatment of phantom limb pain
T., Mourant, R., & Moncrief, R. (2010). Driving rehabilitation
(PLP) based on augmented reality and gaming controlled by
for military personnel recovering from traumatic brain injury
myoelectric pattern recognition: A case study of a chronic PLP
using virtual reality driving simulation: A feasibility study.
patient. Frontiers in Neuroscience, 8(24), 1-7.
Military Medicine, 175(6), 411-416.
Parsons, T.D., Rizzo, A.A., Rogers, S., & York, P. (2009). Virtual
Darter, B.J., & Wilken, J.M. (2011). Gait training with virtual
reality in paediatric rehabilitation: A review. Developmental
reality-based real-time feedback: Improving gait performance
Neurorehabilitation, 12(4), 224-238.
following transfemoral amputation. Physical Therapy, 91(9),
Rabago, C.A., & Wilken, J.M. (2011). Application of a mild trau-
1385-1394.
matic brain injury rehabilitation program in a virtual reality
Dunn, J., Yeo, E., Moghaddampour, P., Chau, B., & Humbert, S.
environment: A case study. Journal of Neurologic Physical
(2017). Virtual and augmented reality in the treatment of phan-
Therapy, 35(4), 185-193.
tom limb pain: A literature review. NeuroRehabilitation, 40(4),
Schultheis, M.T., & Rizzo, A.A. (2001). The application of virtual
595-601.
reality technology for rehabilitation. Rehabilitation Psychol-
Dvorkin, A.Y., Ramaiya, M., Larson, E.B., Zollman, F.S., Hsu,
ogy, 46(3), 296-311.
N., Pacini, S., Shah, A., & Patton, J.L. (2013). A “virtually
Sessoms, P.H., Gottshall, K.R., Collins, J.D., Markham, A.E., Ser-
minimal” visuo-haptic training of attention in severe traumatic
vice, K.A., & Reini, S.A. (2015). Improvements in gait speed
brain injury. Journal of Neuroengineering and Rehabilitation,
and weight shift of persons with traumatic brain injury and
10(92), 1-9.
vestibular dysfunction using a virtual reality computer-assisted
Ferrer-Garcia, M., Gutierrez-Maldonado, J., & Riva, G. (2013).
rehabilitation environment. Military Medicine, 180(3s),
Virtual reality based treatments in eating disorders and obe-
143-149.
sity: A review. Journal of Contemporary Psychotherapy, 43(4),
Winstein, C.J., Stein, J., Arena, R., Bates, B., Cherney, L.R.,
207-221.
Cramer, S.C., Deruyter, F., Eng, J.J., Fisher, B., Harvey, R.L.,
Gamito, P., Oliveira, J., Pacheco, J., Morais, D., Saraiva, T., Lac-
Lang, C.E., MacKay-Lyons, M., Ottenbacher, K.J., Pugh,
erda, R., Baptista, A., Santos, N., Soares, F., Gamito, L., &
S., Reeves, M.J., Richards, L.G., Stiers, W., Zorowitz, R.D.,
Rosa, P. (2011). Traumatic brain injury memory training: A vir-
& American Heart Association Stroke Council, Council on
tual reality online solution. International Journal on Disability
Cardiovascular and Stroke Nursing, Council on Clinical Cardi-
and Human Development, 10(4), 309-312.
ology, and Council on Quality of Care and Outcomes Research.
Gottshall, K.R., & Sessoms, P.H. (2015). Improvements in dizzi-
(2016). Guidelines for adult stroke rehabilitation and recovery:
ness and imbalance results from using a multi disciplinary and
A guideline for healthcare professionals from the American
multi sensory approach to vestibular physical therapy – a case
Heart Association/American Stroke Association. Stroke, 47(6),
study. Frontiers in Systems Neuroscience, 9, 106.
e98-e169.
Hashimoto, D.A., Petrusa, E., Phitayakorn, R., Valle, C.,
Casey, B., & Gee, D. (2017). A proficiency-based vir-
Copyright of NeuroRehabilitation is the property of IOS Press and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.