Mar 16, 2019
Seeing Things Differently: University of Alabama using VR in athlete rehab
By Ryan Vicknair, Jeremy Gsell and Clay Keith

Every clinician knows it can be difficult to keep athletes engaged throughout a long rehab period. After doing the same exercises, in the same room, day after day, monotony inevitably sets in.

Looking to change this, we introduced virtual reality (VR) to our rehabs at the University of Alabama a year and a half ago. Currently, we use it primarily with our football players, but other athletes can access it as needed.

Alabama footballIncorporating VR into our practice aligns with our philosophy for attacking rehabilitation: “creative, aggressive, and objective.” We believe this methodology motivates our staff to think outside the box in terms of the tools we use and the way we build and implement rehabs.

Immediately after we began using VR, we saw it was having the desired effect. There were vast improvements in athlete motivation and commitment throughout the rehabilitation process. VR has a number of benefits, was easy to incorporate into our sports medicine program, and has plenty of practical applications.

Why we use it

By increasing athletes’ engagement and motivation during rehab, while challenging them physically, VR helps recovery go more smoothly. It makes rehab more fun, too, especially for today’s tech-savvy athletes. So instead of dreading their time in the athletic training room, they look forward to slipping on the VR headset and getting to work.

Another benefit of using VR is that it provides more challenging stimuli by virtually transporting the patient to a new location. Research has shown that athletes who think about other tasks or places during their rehab can be pushed to attain new goals that surpass the walls of the athletic training room. As a result, the rehab goes faster.

Being able to take the athlete into a virtual world lets us make exercises more difficult, as well. Changing an athlete’s surroundings completely challenges their proprioception and requires them to adapt, making it much harder to perform even familiar movements.

VR provides more challenging stimuli by virtually transporting the patient to a new location. Research has shown that athletes who think about other tasks or places during their rehab can be pushed to attain new goals that surpass the walls of the athletic training room.

The VR system has also allowed us to use goal-oriented rehabilitation, tying into the objective aspect of our philosophy. The different games and activities we use in VR have scores or times that we can track. Using these records, we can set daily goals or have athletes compete against their scores from a previous session. This adds numerical data to the recovery process that we can compare day to day, which assists in monitoring the progression of a long-term injury.

A final plus is that VR helps players build trust in their injured body part by giving them something else to focus on while performing a rehab exercise instead of what is sore or difficult to perform. For example, an athlete with an ankle injury might be reticent about toe raises. But if we have them shoot a basketball in a virtual game, they have something else to think about besides their ankle. Because they want to make the shot, they might be more encouraged to get up on their toes. This both strengthens their ankle and their confidence in it.

How it started

We originally got the notion to incorporate VR into our rehabilitation programs from the football team in December 2016. The football coaches were already using VR with players to enhance their ability to recall plays and process film from practice. Players would don the VR goggles and watch a 3-D video that was filmed from behind the snap to go through plays and formations.

When we saw what the coaches were doing, we immediately thought VR might be something we could use in rehab. Although we weren’t entirely sure how to institute it, we understood that putting our injured athletes into a different environment would benefit their recoveries.

Knowing almost nothing about the various VR systems, our sports medicine staff reached out to the football team’s video department for guidance. They provided insight into what systems were available, what options might be suitable for our purposes, and how to get set up.

Next, we tried out a few systems. We played the games each one provided and tried to imagine how we could turn them into rehab exercises. Convinced by the experience, we started using VR in rehab with select players in late spring 2017.

Currently, our primary system is the HTC Vive. This is a standard unit that runs from a laptop computer. It retails for $499, and we funded it through our sports medicine budget.

The HTC Vive comes with a 360-degree motion sensor system, a headset that includes the VR goggles, and two handheld controllers. The sensor system picks up the motion of the headset and handheld tools. These movements are then mirrored in the virtual world, allowing the wearer to move freely in the perceived environment.

One benefit of the HTC Vive system is that it can be connected to standard monitors, meaning we can see what the athlete is seeing via a TV in the athletic training room. We can then give them coaching cues and instructions during gameplay.

We have also used a secondary system that involves clipping a VR headset onto a smartphone. The phone is loaded with VR content our video department has shot at our games and practices. This enables us to go to a specific moment from a game or practice and have the athlete rehab while viewing the footage. Unfortunately, we cannot see what the athlete sees with this setup, so giving them cues becomes difficult. However, we can still challenge them with the videos and games.

Powered up

Properly applying VR into rehab takes a great deal of imagination. We haven’t seen any programs specifically for injury recovery within the VR market, but we’ve found ways to work with what is available to reach our goals. This is where the creative aspect of our rehab philosophy comes into play.

Right now, we are using the games that come standard with the HTC Vive VR system, such as Stack, VR Sports, Google Earth, Tilt Brush and Jenga. We typically add some form of external proprioceptive or strengthening component as the game is being played.

For example, we recently used Stack with an athlete who was recovering from an ankle sprain. He eventually entered the phase of his rehab where we wanted to get him up onto his toes. In Stack, he had to place blocks on top of each other. When he got the blocks high enough, he had to get up onto his toes to stack the next block. Because his score increased with each block he stacked, we could determine how long and how often he was on his toes and track his progress.

Stack can be good for rehabbing upper-extremity injuries, too. The game allows athletes to work on developing range of motion without having to think about it, since their focus is on picking up and placing the blocks, not on their body’s movements.

   » ALSO SEE: Post-operative rehab following hip arthroscopy

A popular option in VR Sports is basketball — especially when rehabbing ankle sprains. The task seems simple — the player has to make a 3-pointer with 10 basketballs. However, because we take an aggressive approach with rehab, we increase the difficulty by having them shoot while standing on an unstable surface, such as an Airex pad or DynaDisc. As a result, we enhance the proprioceptive and strengthening factors of the exercise. We can also use this activity for single-leg balance work.

Shooting 3-pointers in VR Sports is better than going to the basketball court and shooting there because the virtual environment takes the athlete’s focus off their injury. With the VR goggles on, they don’t think of it as rehabbing or performing exercises — they are simply playing a game.

With the Google Earth module, the athlete begins by getting into a squat position. Then, they hold the squat and move the hand controllers to navigate through the simulated planet to find specific locations. This can be done while standing on the floor or on an unstable surface, and it is a common exercise for athletes coming off a lower-extremity injury. Times Square in New York City, the Coliseum in Rome, or even the athlete’s hometown are a few of the common locations we’ve used.

Tilt Brush is an excellent game for rehabbing an upper-extremity injury because it allows the athlete to draw in a 360-degree virtual world. They can paint or create art and then interact with it. To emphasize rehab, we have strapped cuff weights to athletes’ wrists or used bands to provide resistance while having them draw in the game.

For the Jenga program, the player is in a room with a live Jenga set. They remove bricks from the stack until they fail and the stack crashes — just like in real-life Jenga. We have had athletes perform single-leg balance exercises while playing this game. It’s great because it allows them to get to a more functional state, particularly after recovering from a lower-extremity injury.

As far as when to use VR for rehab, we typically reserve it for the later stages of rehab when the athlete is ready for balance or proprioceptive work. It is considered an addition to any traditional rehabilitation plan.

VR can be inserted earlier in the rehab process, but it depends on the athlete and where they are with their recovery. It’s up to the athletic trainer to decide whether VR is appropriate for each athlete.

In our experience, the only limitations with VR come from the technology itself. Meaning, we are limited in what games we can use. We are hoping to see more treatment- and rehab-based games come out for these systems in the future.

For others interested in VR, it’s important to find a system that is budget-friendly and has engaging games. However, expect to tap into your creativity to make the games work for you.

Overall, we find VR to be a great tool that fills in gaps in rehab programs. There is a strong proprioceptive component for lower-extremity injuries as well as many possibilities for rehabbing upper-extremity injuries.

In the past 18 months, we have only scratched the surface of the many ways to include VR to challenge our athletes in rehab. There is a tremendous amount of potential to this technology as we move forward. The VR realm is constantly changing, providing endless opportunities for new challenges. So far, VR has been a strong addition to our athletic training room, and we look forward to continued success.

Ryan Vicknair, MA, LAT, ATC, is an Athletic Trainer; Jeremy Gsell, MA, LAT, ATC, is Director of Rehabilitation Services for Football; and Clay Keith is an Athletic Performance Analyst at the University of Alabama.

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