User-Centered Development of a Personalized Adaptive Mirror Therapy for Upper-Limb Post-Stroke Rehabilitation using Virtual Reality and Myoelectric Control

Paolo De Pasquale^1*Daniela De Bartolo²Marta Russo^3,4Denise J Berger^4,5Antonella Maselli^4,6Daniele Borzelli^4,6Emma Colamarino^7,8Donatella Mattia⁸Christian Nissler⁹Markus Nowak⁹Elena Falomo¹⁰Javier Morras¹⁰Moco Schiller¹⁰Claudio Castellini⁹Giovanni Morone^11,2Andrea d'Avella^12,4*

• ¹Bonino Pulejo Neurology Center (IRCCS), Messina, Italy
• ²Laboratorio Sperimentale di Neuroriabilitazione Clinica, Fondazione Santa Lucia Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
• ³Istituto di Scienze e Tecnologie della Cognizione, Consiglio Nazionale delle Ricerche, Rome, Italy
• ⁴Laboratorio di Fisiologia Neuromotoria, Fondazione Santa Lucia Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
• ⁵Dipartimento di Medicina dei Sistemi e Centro di Biomedicina Spaziale, Universita degli Studi di Roma Tor Vergata, Rome, Italy
• ⁶Universita degli Studi di Messina Dipartimento di Scienze biomediche odontoiatriche e delle immagini morfologiche e funzionali, Messina, Italy
• ⁷Dipartimento di ingegneria Informatica, Automatica e Gestionale, Universita degli Studi di Roma La Sapienza, Rome, Italy
• ⁸Laboratorio di Immagini Neuroelettriche e Interfacce Cervello-Computer, Fondazione Santa Lucia Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
• ⁹Deutsches Zentrum fur Luft- und Raumfahrt DLR Institut fur Robotik und Mechatronik, Oberpfaffenhofen, Germany
• ¹⁰NEEEU Spaces GmbH, Berlin, Germany
• ¹¹Universita degli Studi dell'Aquila Dipartimento di Medicina Clinica Sanita Pubblica Scienze della Vita e dell'Ambiente, L'Aquila, Italy
• ¹²Universita degli Studi di Roma Tor Vergata Dipartimento di Biologia, Rome, Italy

Introduction: Cerebral stroke often results in significant motor deficits, including contralateral hemiparesis of the upper limb. Rehabilitation protocols with high-intensity and task-specific exercises can improve these deficits. Recent technological advancements in virtual reality (VR), myoelectric control, and exergames may be exploited to enhance rehabilitation effectiveness. However, novel rehabilitation approaches combining these novel methodologies have rarely been developed with the active involvement of both therapists and patients. Methods: An interdisciplinary team developed a novel system, Validation of the Virtual Therapy Arm (VVITA), for post-stroke upper-limb rehabilitation combining VR, myoelectric control, and exergames using a user-centered design (UCD) approach. The VVITA hardware includes a head-mounted VR display, motion tracking devices integrated in the VR system, and wireless armbands to record electromyographic (EMG) signals, providing an interactive virtual environment for immersive rehabilitation exercises implementing a virtual mirror therapy. Assistance and task difficulty are adjusted dynamically based on patient performance, promoting active participation and motor learning. Results: The development process involved iterative phases, involving focus groups with stroke patients, therapists, and researchers. A pilot study with four stroke survivors assessed the system's feasibility, demonstrating its potential for personalized and adaptive rehabilitation. Conclusion: The VVITA system enhances mirror therapy by integrating VR and myoelectric control, providing a tailored approach to upper-limb post-stroke rehabilitation. The UCD approach ensured the system met patient and therapist needs, showing promise for improving motor recovery and rehabilitation outcomes.