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Abstract
Virtual reality (VR) assisted rehabilitation system is being used more commonly in supplementing upper extremities (UE) functional rehabilitation. Mirror therapy (MT) is reportedly a useful training in encouraging motor functional recovery. However, the majority of current systems are not compatible with magnetic resonance (MR) environments. Resting-state functional magnetic resonance imaging (rs-fMRI) data, for measuring neuronal recovery status, can only be collected by these systems after the participants have been done with the VR therapy. As a result, real-time observation of the brain in working status remains unattainable. To address this challenge, we developed a novel MR-compatible VR system for Assessment of UE motor functions (MR.VRA). Three different modes are provided adapting to a participant’s appropriate levels of sensorimotor cortex impairment, including a unilateral-contralateral mode, a unilateral-ipsilateral mode, and a unilateral-bilateral mode. Twenty healthy subjects were recruited to validate MR.VRA for UE function rehabilitation and assessment in three fMRI tasks. The results showed that MR.VRA succeeded in conducting the fMRI tasks in the MR scanner bore while stimulating the sensorimotor neurons and mirror neurons using its embedded therapies. The findings suggested that MR.VRA may be a promising alternative for assessing neurorehabilitation of stroke patients with UE motor function impairment in MR environment, which allows inspection of direct imaging evidence of activities of neurons in the cortices related to UE motor functions.
Links to Paper and Supplementary Materials
Main Paper (Open Access Version): https://papers.miccai.org/miccai-2024/paper/3035_paper.pdf
SharedIt Link: https://rdcu.be/dV5vW
SpringerLink (DOI): https://doi.org/10.1007/978-3-031-72089-5_6
Supplementary Material: N/A
Link to the Code Repository
N/A
Link to the Dataset(s)
N/A
BibTex
@InProceedings{Wan_An_MICCAI2024,
author = { Wang, Xiaocheng and Mekbib, D. B. and Zhou, Tian and Zhu, Junming and Zhang, Li and Cheng, Ruidong and Zhang, Jianmin and Ye, Xiangming and Xu, Dongrong},
title = { { An MR-Compatible Virtual Reality System for Assessing Neuronal Plasticity of Sensorimotor Neurons and Mirror Neurons } },
booktitle = {proceedings of Medical Image Computing and Computer Assisted Intervention -- MICCAI 2024},
year = {2024},
publisher = {Springer Nature Switzerland},
volume = {LNCS 15006},
month = {October},
page = {57 -- 66}
}
Reviews
Review #1
- Please describe the contribution of the paper
Two fold; the description of a new MR compatible virtual rehabilitation platform for the upper extremity and an observational feasibility study on healthy participants regarding the brain response when using this new VR platform.
- Please list the main strengths of the paper; you should write about a novel formulation, an original way to use data, demonstration of clinical feasibility, a novel application, a particularly strong evaluation, or anything else that is a strong aspect of this work. Please provide details, for instance, if a method is novel, explain what aspect is novel and why this is interesting.
Strong numbers for a feasibility study and otherwise reasonably well conducted processing/analysis.
- Please list the main weaknesses of the paper. Please provide details, for instance, if you think a method is not novel, explain why and provide a reference to prior work.
Certainly not the first MR VR system; [Prochnow et al, 2013] or [Mraz et al 2003] come to mind, and very expectable findings (I reckon this latter can also be considered a strength from a nomological point of view).
- Please rate the clarity and organization of this paper
Very Good
- Please comment on the reproducibility of the paper. Please be aware that providing code and data is a plus, but not a requirement for acceptance.
The submission does not mention open access to source code or data but provides a clear and detailed description of the algorithm to ensure reproducibility.
- Do you have any additional comments regarding the paper’s reproducibility?
N/A
- Please provide detailed and constructive comments for the authors. Please also refer to our Reviewer’s guide on what makes a good review. Pay specific attention to the different assessment criteria for the different paper categories (MIC, CAI, Clinical Translation of Methodology, Health Equity): https://conferences.miccai.org/2024/en/REVIEWER-GUIDELINES.html
- This is a feasibility study yet there is no attempt at measuring anything related to clinical impact (this is a healthy cohort anyways, but the weakness is more in the lack of the right endpoints), usability/acceptability, motivational aspects (often a strong motivator for VR in motor rehab), etc
- Game/Task variability is very reduced, which obviously will constraint its applicability in a real therapy.
- The whole results discussion remains at qualitative level, yet SPM can afford quantitative both subject specific and group level analysis. Any reason for not focusing on this more quantitative part?
- You mention “Therefore, it is confident that MR, VRA will be able to effectively assess UE motor function in patients…” but; 1) this is actually your hypothesis so you shouldn’t take it for granted, and 2) you are neither measuring patients nor measuring motor function e.g. with fugl-meyer or other. Do you mind justifying your claim?
- Suggestion: The intro pictures a very positive portrait of the success of virtual neurorehabilitation. While indeed VR brought some fresh air to neurorehabilitation when it started in the mid 90s and somewhat boomed in the 2000s, it seems to have been stalled for a while now. Back in the day, Langhorne et al (2009) published what was a heads-up review in which the effectiveness of the different approaches to rehabilitation were more or less inconsequential for the arm -i.e. as long as the patient did the exercises, some minimal progress was guaranteed regardless of the approach- and negligible for the hand. VR was then included as part of the robotics subset, but my point here is that VR effectiveness was certainly not above others, and it also have some drawbacks e.g. transferability, acceptability, etc None of these is recognised in the all-pink intro here. Perhaps a more neutral tone would be more appropriate.
- Rate the paper on a scale of 1-6, 6 being the strongest (6-4: accept; 3-1: reject). Please use the entire range of the distribution. Spreading the score helps create a distribution for decision-making
Weak Accept — could be accepted, dependent on rebuttal (4)
- Please justify your recommendation. What were the major factors that led you to your overall score for this paper?
When a new platform for virtual neurorehabilitation is proposed, feasibility studies is a must. And in that sense, this paper delivers what says on the tin. But it feels a bit outdated (in the sense that we have MR compatible options for some time now) and even if particularising for the mirror therapy, it feels lacking some needed endpoints even if you observe a healthy cohort.
- Reviewer confidence
Very confident (4)
- [Post rebuttal] After reading the author’s rebuttal, state your overall opinion of the paper if it has been changed
N/A
- [Post rebuttal] Please justify your decision
N/A
Review #2
- Please describe the contribution of the paper
The authors developed a novel MR compatible VR system for Assessment of upper extremity motor functions (MR.VRA)
- Please list the main strengths of the paper; you should write about a novel formulation, an original way to use data, demonstration of clinical feasibility, a novel application, a particularly strong evaluation, or anything else that is a strong aspect of this work. Please provide details, for instance, if a method is novel, explain what aspect is novel and why this is interesting.
Introducing an MR compatible VR system allows the use of fMRI to assess neuro rehabilitation. The introduction is well written and very helpful for people not in the field.
- Please list the main weaknesses of the paper. Please provide details, for instance, if you think a method is not novel, explain why and provide a reference to prior work.
Minor English language problems throughout the text. Example at the beginning of 2.1: The MR.VRA hardware system… instead of “The framework of the hardware system of MR.VRA…”
- Please rate the clarity and organization of this paper
Very Good
- Please comment on the reproducibility of the paper. Please be aware that providing code and data is a plus, but not a requirement for acceptance.
The submission does not provide sufficient information for reproducibility.
- Do you have any additional comments regarding the paper’s reproducibility?
The details provided about the data processing are insufficient for independent reproduction. Are the VR tasks publicly available?
- Please provide detailed and constructive comments for the authors. Please also refer to our Reviewer’s guide on what makes a good review. Pay specific attention to the different assessment criteria for the different paper categories (MIC, CAI, Clinical Translation of Methodology, Health Equity): https://conferences.miccai.org/2024/en/REVIEWER-GUIDELINES.html
Abstract: “The results showed that MR.VRA succeeded in conducting the fMRI tasks in the MR scanner bore while…” It is not clear what the authors are trying to say. Did you mean: allowed to perform? After reading page 3 top, it is unclear how the information from the LCD reaches the subject’s eyes. The authors state that the LCD is behind the bore. Normally the head coil mirror is facing towards the feet of the subject.
- Rate the paper on a scale of 1-6, 6 being the strongest (6-4: accept; 3-1: reject). Please use the entire range of the distribution. Spreading the score helps create a distribution for decision-making
Weak Accept — could be accepted, dependent on rebuttal (4)
- Please justify your recommendation. What were the major factors that led you to your overall score for this paper?
This paper fits nicely into the clinical translation category. More specifics/details about the VR scenes and data processing would be helpful.
- Reviewer confidence
Somewhat confident (2)
- [Post rebuttal] After reading the author’s rebuttal, state your overall opinion of the paper if it has been changed
N/A
- [Post rebuttal] Please justify your decision
N/A
Review #3
- Please describe the contribution of the paper
The authors have developed a novel MR- compatible VR system for Assessment of UE motor functions in order to be able to assess neuronal activity during mirrored therapeutic training.
Participants are required to use the button box in order to control a virtual arm, and catch a virtual ball to put it in a basket. During that time, a bloc design task fMRI was acquired (5 blocs per tasks, 2 tasks per participants). 19 participants (of the 20 recruited) underwent the experiment, and activation was see in the precentral and postcentral gyrus.
- Please list the main strengths of the paper; you should write about a novel formulation, an original way to use data, demonstration of clinical feasibility, a novel application, a particularly strong evaluation, or anything else that is a strong aspect of this work. Please provide details, for instance, if a method is novel, explain what aspect is novel and why this is interesting.
Interesting paper, with a promising title, and interesting and innovative idea.
- Please list the main weaknesses of the paper. Please provide details, for instance, if you think a method is not novel, explain why and provide a reference to prior work.
It would have been interesting to know more about how the button box directs the virtual arm (only up, down, left, right, or is it in 3D?). Using a button press controller requires minimal activation of the limb – and therefore motor cortex, but still requires some finger dexterity, which in the case of stroke might not be feasible for the subjects (typically, they might recover an arm function with proximal control before the distal control). I think however that pushing on 4 buttons will not allow a great assessment of the neuronal plasticity, as again it only assess distal function (fingers) and not arm; but it is a great start. They were able to elicit some activation on 19 normal controls, but that might be harder to elicit in actual patients.
- Please rate the clarity and organization of this paper
Satisfactory
- Please comment on the reproducibility of the paper. Please be aware that providing code and data is a plus, but not a requirement for acceptance.
The submission does not provide sufficient information for reproducibility.
- Do you have any additional comments regarding the paper’s reproducibility?
N/A
- Please provide detailed and constructive comments for the authors. Please also refer to our Reviewer’s guide on what makes a good review. Pay specific attention to the different assessment criteria for the different paper categories (MIC, CAI, Clinical Translation of Methodology, Health Equity): https://conferences.miccai.org/2024/en/REVIEWER-GUIDELINES.html
Innovative idea with clinically significant potential outcomes. Looking at the title, the CAI component would be the design of the system, which could have been better described, as it seems through the description available to be only a box with multiple buttons (so not that innovative). They were however able to get some activation in normal subjects with their different algorithms.
- Rate the paper on a scale of 1-6, 6 being the strongest (6-4: accept; 3-1: reject). Please use the entire range of the distribution. Spreading the score helps create a distribution for decision-making
Weak Accept — could be accepted, dependent on rebuttal (4)
- Please justify your recommendation. What were the major factors that led you to your overall score for this paper?
Would have liked to hear more about the system. If limited to a button box, then I am questioning the clinical impact, as it only make the participant use fingers, which are not representative of the upper extremity, especially in the case of strokes.
- Reviewer confidence
Confident but not absolutely certain (3)
- [Post rebuttal] After reading the author’s rebuttal, state your overall opinion of the paper if it has been changed
N/A
- [Post rebuttal] Please justify your decision
N/A
Author Feedback
We appreciate the reviewers’ valuable feedbacks. We are committed to revising our paper accordingly. (R1-1)In our finalized version, we will cite and acknowledge the contributions of the studies by [Prochnow et al 2013] & [Mraz et al 2003], which were pioneers in this area. Extended from the VR system in our previous studies, our MR.VRA system is now equipped with an MR-compatibility at 3.0/7.0-tesla using a high-quality LCD display to provide patients with a virtual environment with improved personal experience. Button box serves as an accessible interface that allows for real-time motion controls and interaction during the fMRI tasks. (R1-2)Clinical impact result. The reviewer is correct that we used only healthy subjects to test the feasibility, and thank the reviewers for their understanding and agreeing that this is an important first step to make MR.VRA system further useful for clinical uses, while the original non-MR-compatible version of this system was already clinically used in rehabilitation of stroke patients at two local major hospitals, which proved useful and effective based on resting-fMRI data. To report its clinical results with a hardware upgrade is our next step once this first report is accepted by the community. (R1-3)Quantitative Analysis: We actually have conducted extensive quantitative analyses on the task-fMRI data. All activated brain areas, including Brodmann Area designations, MNI coordinates, and t-values have been meticulously recorded. Limited by the length allowance of this conference, we are unable to report the quantitative analyses in greater details，but will try to fit in as much as we can to the text in the camera-ready revision. Our full-length journal version of this paper will definitely delve into these suggestions. (R1-4)Effectiveness Claim. Prior to the MR.VRA system’s development, a non-MR-compatible immersive VR system for UE rehabilitation was already in use. Its effectiveness in stroke patients was validated through scales like the Fugl-Meyer Motor Scale and resting-fMRI. We therefore feel confident that MR.VRA will be capable of effectively functioning on UE motor functions following up this feasibility study. Although not emphasized in the manuscript due to the rule of double-blind review, we will highlight this part in the camera-ready version. (R1-5)Balance in introduction. We recognize the need for a balanced perspective on the introduction of MR.VRA system. While we aimed to highlight the potential of MR.VRA, we understand the importance of acknowledging the current challenges and limitations. We now have revised the introduction to provide a more neutral and comprehensive overview, including the historical context and a discussion on the varied effectiveness of MR.VRA. (R3-1)Minor English language problems. Thank you for your careful reading and pointing out the grammatical errors and ambiguous statement present in the text. We apologize for these defects and confusion. We will thoroughly polish the text and ensure its best quality in the camera-ready version. (R3-2)Head coil mirror. The head coil mounts an angle-adjustable mirror directly in front of the patient’s eyes, at a distance of about 8cm with a comfortable viewing field of the projected scene. (R4-1)The direction controlled by button box. Button box has four buttons for moving along four directions (front, back, left, and right). We have fixed the distance between the virtual arm and the virtual table. (R4-2)Limitation of button box. We must acknowledge that the use of a button box may seem limiting in this first-stage report. As MR.VRA system has been proven effective on healthy subjects and in the past on stroke patients, we are conducting the next phase of experiment that will use a joystick to facilitate patient use and for the VR system to measure the proximal function of the stroke patients. Reproducibility. MR.VRA will be available for free non-commercial uses once its software copyright is authorized.
Meta-Review
Meta-review not available, early accepted paper.