Authors:

Jisun Yoon, MD
Min Ho Chun, MD, PhD Brain Tumor
Sook Joung Lee, MD
Bo Ryun Kim, MD

Affiliations:
From the Department of Rehabilitation ORIGINAL RESEARCH ARTICLE
Medicine, Asan Medical Center,
University of Ulsan College of Medicine,
Seoul (JY, MHC); Department of
Physical Medicine and Rehabilitation,
Dong-A University College of Medicine, Effect of Virtual RealityYBased
Busan (SJL); and Department of
Rehabilitation Medicine, Jeju National
University Hospital, University of Jeju
Rehabilitation on Upper-Extremity
College of Medicine, Jeju, Republic of
Korea (BRK).
Function in Patients with Brain Tumor
Controlled Trial
Correspondence:
All correspondence and requests for
reprints should be addressed to: ABSTRACT
Min Ho Chun, MD, PhD, Department Yoon J, Chun MH, Lee SJ, Kim BR: Effect of virtual realityYbased rehabilitation
of Rehabilitation Medicine, Asan
Medical Center, University of Ulsan on upper-extremity function in patients with brain tumor: controlled trial. Am J
College of Medicine, 88, Olympic-Ro Phys Med Rehabil 2015;94:449Y459.
43-Gil, Songpa-gu, Seoul 138Y736,
Republic of Korea.
Objective: The aim of this study was to evaluate the benefit of virtual
realityYbased rehabilitation on upper-extremity function in patients with brain tumor.
Disclosures: Design: Patients with upper-extremity dysfunction were divided into age-
No commercial party having a direct matched and tumor typeYmatched two groups. The intervention group performed
financial interest in the results of the
research supporting this article has or the virtual reality program 30 mins per session for 9 sessions and conventional
will confer a benefit upon the authors occupational therapy 30 mins per session for 6 sessions for 3 wks, whereas the
or upon any organization with which
control group received conventional occupational therapy alone 30 mins per
the authors are associated.
Financial disclosure statements have session for 15 sessions for 3 wks. The Box and Block test, the Manual Function
been obtained, and no conflicts of test, and the Fugl-Meyer scale were used to evaluate upper-extremity function.
interest have been reported by the
authors or by any individuals in control The Korean version of the Modified Barthel Index was used to assess activities of
of the content of this article. daily living.
Results: Forty patients completed the study (20 for each group). Each group
0894-9115/15/9406-0449 exhibited significant posttreatment improvements in the Box and Block test,
American Journal of Physical Manual Function test, Fugl-Meyer scale, and Korean version of the Modified
Medicine & Rehabilitation
Copyright * 2014 Wolters Kluwer
Barthel Index scores. The Box and Block test, the Fugl-Meyer scale, and the
Health, Inc. All rights reserved. Manual Function test showed greater improvements in shoulder/elbow/forearm
function in the intervention group and hand function in the control group.
DOI: 10.1097/PHM.0000000000000192
Conclusions: Virtual realityYbased rehabilitation combined with conventional
occupational therapy may be more effective than conventional occupational ther-
apy, especially for proximal upper-extremity function in patients with brain tumor.
Further studies considering hand function, such as use of virtual reality programs
that targeting hand use, are required.
Key Words: Brain Tumor, Upper-Extremity Function, Virtual Reality, Occupational Therapy

www.ajpmr.com Virtual Reality–Based Rehabilitation on UE Function 449

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 P rimary brain tumors account for less than 2%
of all malignancies and generally leave the affected
patient with significant functional impairment.1,2
Aggressive treatments based on surgery, radiation,
and chemotherapy frequently lead to improved sur-
vival rates for patients with brain tumors. None-
theless, brain tumors continue to cause pronounced
neurologic deficits despite these interventions. Cog-
nitive impairment is the most commonly reported
deficit, at an occurrence rate of 80%, followed by
motor weakness (78%), visual-perceptual deficits
(53%), sensory loss (38%), and bowel and/or blad-
der dysfunction (37%). The neurologic impairments
are similar to those found in patients who have had
a stroke or a traumatic brain injury.3
Rehabilitation therapy in patients with brain
tumor has gained prominence during the past three
decades, and several studies indicated that indi-
viduals with brain tumors make significant func-
tional strides after rehabilitation.4Y7 For example,
Huang et al.8 demonstrated that patients with brain
tumor in acute inpatient rehabilitation centers had
a decreased length of stay compared with patients
with stroke and also achieved functional gains
comparable with those of stroke survivors. Along
the same lines, O’Dell et al.2 found that brain tumor
patients with appropriate rehabilitative treatment
achieved functional gains approaching those of pa-
tients with brain injury.
Virtual reality (VR) can be defined as the Buse
of interactive simulations created with computer
hardware and software to present users with op-
portunities to engage in environments that appear
and feel similar to real-world objects and events.[9
VR programs are used in various kinds of vocational
training, including flight simulations for pilots and
driving simulations for automobile operators.10 Re-
cently, VR programs have also been incorporated
into neurologic rehabilitation agenda to improve
upper-extremity (UE) function,11 lower extremity
function,12 and gait.12 In addition, VR is widely used
in the field of brain disease for cognitive rehabilita-
tion.13 Heretofore, most investigations of VR ther-
apy have been directed toward improving motor
function in patients with stroke and traumatic brain
injuries. Several randomized controlled trials have
compared VR-mediated therapy with conventional
occupational therapy (OT) for the enhancement of
UE function and have shown significant improve-
ments in the Box and Block test (BBT) of manual
dexterity, the Fugl-Meyer scale (FMS), the Manual
Function test (MFT), and the Wolf Motor Function
test score of UE motor ability.14,15
450 Yoon et al.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
To the best of the authors’ knowledge, no
investigations have been performed to date regard-
ing the effect of VR-based rehabilitation on the res-
toration of UE function in patients with brain
tumor. The aim of this study was to evaluate the
ability of VR-based rehabilitation to improve hand,
arm, and shoulder function in these individuals.
The primary outcome of this study was an im-
provement in UE function evaluated by the BBT,
the MFT, and the FMS. The secondary outcome was
an improvement in activities of daily living evalu-
ated by the Korean version of the Modified Barthel
Index (K-MBI). The authors hypothesized that com-
bining VR-based rehabilitation with conventional
OT would help to improve UE function in patients
with brain tumor compared with conventional OT.
METHODS
Study Participants
Patients with UE dysfunction as a consequence
of brain tumor were recruited from an inpatient
clinic in the Department of Rehabilitation Medi-
cine of the Asan Medical Center, Seoul, Republic
of Korea, from March 1, 2011, through March 1,
2012. Inclusion criteria were as follows: (1) a brain
tumor diagnosis with a stable status after the com-
pletion of proper management (surgery, chemo-
therapy, or radiation therapy); (2) patients with a
Korean version Mini-Mental State Examination score
of greater than 20 who are capable of understand-
ing the therapist’s instructions; (3) a Brunnstrom
stage of higher than 2 (2: hyperreflexia, emergence
of spasticity and synergies, minimal voluntary move-
ment in the affected limbs) corresponding to the
affected UE; (4) a score on the Modified Ashworth
spasticity scale of less than 2 (2: more marked in-
crease in muscle tone through most of the range
of motion but affected part is easily moved); and
(5) motor power grade of the affected shoulder of
higher than Bpoor[ (poor strength corresponds to
inability to perform movements against gravity but
complete range of motion when the pull of gravity
is eliminated). Exclusion criteria were as follows: (1)
a diagnosis of global aphasia; (2) decreased sitting
balance; (3) a recurrent brain tumor; (4) perceptual-
cognitive dysfunction (visuospatial neglect and cog-
nitive function evaluated by the Albert test16 and
the Korean version Mini-Mental State Examina-
tion17); (5) musculoskeletal problems and/or pe-
ripheral neuropathy of the affected limb; and (6)
medical instability (acute inflammation or infec-
tion such as pneumonia, urinary tract infection,
and sepsis).
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015
 The patients were allocated into two groups by
developing the stratified random sampling numbers
by dividing strata using two variables (age, type of
tumor). All participants provided written informed
consent before the initiation of the study. The study
protocol was approved by the Research Ethics Com-
mittee of the Asan Medical Center.
Study Protocol
The individuals in the intervention group car-
ried out the VR programs described below for
3 wks at a frequency of 30 mins per day, three times
per week (nine sessions). The patients in the in-
tervention group also received conventional OT for
3 wks at a frequency of 30 mins per day, two times
per week (6 sessions), whereas the control group
received conventional OT alone for 3 wks at a fre-
quency of 30 mins per day, five times per week
(15 sessions). For the duration of this study, all
participants received conventional rehabilitation in-
cluding physical, occupational, and cognitive thera-
pies of the same intensity and duration.
Conventional OT consisted of range of motion
exercises, fine motor training, and strengthening
UE exercises.18 Range of motion exercises consisted
of overhead pulley, range of motion arc, and insert-
ing rings to a horizontal bar. Fine motor training
consisted of turning coins, tapping of the thumb and
the index finger, as well as inserting a piece of wood
into small holes in a pegboard.19 Strengthening
exercises consisted of upper body exerciser, sanding,
weight pulley exercises, and using a Theraband
or lifting a dumbbell. Each exercise took approxi-
mately 10 mins.
VR-based rehabilitation was performed by an
occupational therapist proficient in the use of the
Interactive Rehabilitation and Exercise (IREX) Sys-
FIGURE 1 The virtual reality experimental setup of the IREX System (Vivid Group, Toronto, Canada).
www.ajpmr.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
tem (Vivid Group, Toronto, Canada), described below
(GestureTek Health, IREX). Therapists were blinded
to the study design.
The IREX System VR environment entails a
television monitor, a video camera, a computer rec-
ognition glove, virtual objects, and a number of VR
programs (Fig. 1). Video cameras placed the patients
within the VR environment by analyzing their posi-
tions and movements. Computer recognition gloves
also read the patients’ reactions (responsive move-
ments) and transferred them to the VR system. The
patient was able to see his/her own body movement
in real time, which allowed the patient to be im-
mersed inside the virtual environment.
Six VR programs (Birds and Balls, Conveyor,
Drums, Juggler, Coconuts, and Soccer) were selected
from a total of 20 available programs (Fig. 2). The
Birds and Balls program involves balls appearing on
the screen from various directions. The balls burst
into birds when the patient touches them by using
his/her hand movements. The Coconuts program
denotes a basket that moves from the left or the
right across the screen in response to the patient’s
arm movements. The aim of the game is to use the
basket to catch the coconuts falling from the upper
portion of the screen. The Conveyor program de-
picts two conveyor belts located at the left and
the right hand side of the screen, with boxes
appearing from either side. Patients are asked to use
their hand movements to shift the boxes from one
conveyer belt to the other. The Juggler program
requires the patient to keep several balls simulta-
neously moving in the air with his/her hands. The
Drum program asks the patient to use his/her hands
to play a drum along with the rhythm of music.
Finally, the Soccer program depicts a soccer ball
flying toward the patient, who is asked to stop the
ball by using his/her hand as a goalkeeper. These
Virtual Reality–Based Rehabilitation on UE Function 451
 FIGURE 2 Six VR programs used in this study. A, birds and balls; B, conveyor; C, drums; D, juggler; E, coconuts; F, soccer.
six programs specifically demand UE movements
such as shoulder flexor/adductor/abductor, elbow
flexor, or elbow extensor muscles and can be per-
formed in a standing position or a sitting position.
Each program provided background music re-
lated to the game. Degrees of difficulty were set
by the therapist or by the request of the patient,
ranging from levels 1 to 10. As the patients’ ability
to perform the exercise games increased, the ther-
apist gradually challenged them by regulating the
objects’ speeds, numbers, intervals, and angles, as
appropriate for the patients’ condition, except in the
case of the Drum program. Only total beat numbers
during treatment were shown on the screen at the
end of the Drum program. Each program was
performed for 3 mins, with instructions given by
the occupational therapist, followed by a break of
2 mins between programs (30 mins total session
time). During the 2 mins of interval time, the
therapist changed and prepared the next program
and performed range of motion exercises with the
452 Yoon et al.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
UE of the patient. The patients were asked to
mainly use the affected UE, but some of the pro-
grams required the use of both UEs. A glove was
applied only to the paretic arm. By displaying the
points gained on the screen, the therapist provided
continuous feedback to the patients during the
treatment session.
Evaluation of UE Function
Initial evaluations of UE function were per-
formed using the Brunnstrom approach, which
comprises six proposed stages of motor power re-
covery; the Modified Ashworth scale for grading
spasticity; as well as the MFT, the BBT, and the
FMS. To compare initial motor power of the affected
UE, a manual muscle test was performed. On this
scale, 0 indicates no function (lack of contraction);
1, trace function (slight contraction with no move-
ment); 2, poor function (full range of motion in the
absence of gravity); 3, fair function (full range of
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015
motion against the gravity); 4, good function (full
range of motion, some resistance); and 5, normal
function (full range of motion, full resistance). The
manual muscle test is the most commonly used
evaluation tool for documenting impairment in
muscle strength.20 To evaluate gross manual dex-
terity, the BBT was used.21 The patient was required
to grasp one block at a time with his/her affected
hand, transport the block over a partition, and place
as many blocks as possible into a box on the opposite
side within 60 secs; the number of blocks that were
successfully moved was counted. The MFT measures
gross and fine motor function in the UE on a scale
of 0Y32, and its reliability is considered excellent
(intraclass correlation coefficient, 0.99).22 Its scores
are divided into shoulder/elbow/forearm (S/E/F) and
hand dexterity segments, each of which is scored
from 0 to 16. The motor subset of the FMS for the
UE, which has a scale from 0 to 66, was used to assess
sensation, range of motion, reflexes, synergy, as well
as fine and gross hand movements; its reliability and
validity are considered good (intraclass correlation
coefficient, 0.97).23,24
The primary outcome was evaluated by the
BBT, the MFT, and the FMS, and the secondary
outcome was evaluated by the K-MBI, which was
used to assess the activities of daily living. The re-
liability and the validity of the K-MBI, which was
translated by six senior Korean physiatrists using
the fifth version of the MBI, were approved.25
Follow-up evaluations were conducted in all pa-
tients by applying the MFT, the BBT, the FMS, and
the K-MBI immediately after a 3-wk treatment pe-
riod. Initial and follow-up evaluations were per-
formed by an experienced occupational therapist
who was blinded to the group allocation.
Statistical Analysis
All variables were analyzed using the Statis-
tical Package for the Social Sciences, version 18.0
(Statistical Package for the Social Sciences Inc,
Chicago, IL). Statistical significance was defined
as a P value of less than 0.05. Missing data were
dealt with by the simple mean imputation method,
whereby the missing value is replaced with the mean
of the group. Because the data were not normally
distributed, nonparametric tests were conducted.
Median values with interquartile range were pres-
ented instead of mean values with standard devia-
tion in the data that were not normally distributed.
The Wilcoxon’s signed-rank test was used to analyze
changes in UE function and activities of daily living
over time in each group. The Mann-Whitney U test
was used for comparison of assessment score differ-
ences between the intervention and control groups
(for all subjects and for subjects subdivided into
groups of benign/malignant tumor). In addition,

TABLE 1 Demographic and baseline characteristics of the study participants

Characteristics Intervention (n = 20) Control (n = 20) P
Age, yrs 48.6 (11.3) 50.0 (17.5) 0.99
Sex (male/female) 9:11 8:12 0.74
Type of tumor
Meningioma 5 4 0.75
Glioblastoma 5 5
Low-grade astrocytoma 2 2
Metastatic tumor 4 4
Schwannoma 1 2
Others (PNET, PCNSL) 3 3
Benign/malignant 9:11 11:9 0.53
Location (right/left/both) 6:9:5 6:8:6 0.54
Disease duration, mos 8.1 (5.5) 9.8 (6.1) 0.33
Treatment
Resection 9 8 0.80
Resection, CCRT 4 6
Resection, radiation 4 5
GKRS 2 1
Radiation only 1 0
Values are given as absolute numbers or as mean (standard deviation).
Categorical variables: W2 test or Fisher’s exact test.
Continuous variables: Mann-Whitney U test.
CCRT, concurrent chemoradiation therapy; GKRS, gamma knife radiation surgery; PCNSL, primary central nervous system
lymphoma; PNET, primitive neuroectodermal tumor.

www.ajpmr.com Virtual Reality–Based Rehabilitation on UE Function 453

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 the Mann-Whitney U test was used for evaluating
differences between benign and malignant tumor in
the intervention and control groups.
RESULTS
Sixty patients with impaired UE motor func-
tion as a result of brain tumors were initially eval-
uated. Thirteen patients were excluded for cognitive
impairment, global aphasia, severe shoulder pain on
the affected side, and recurred brain tumor. The
remaining 47 individuals met this study’s inclusion
criteria and were enrolled in the study. Twenty-four
patients were assigned to the intervention group
(VR-based therapy combined with conventional OT),
and 23 patients were assigned to the control group
(conventional OT alone). The groups were closely
matched according to the participants’ age and type
of tumor (Table 1). Four patients in the interven-
tion group and three patients in the control group
FIGURE 3 Flow chart for subject selection and assignment in this study.
454 Yoon et al.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
dropped out of the study because of various issues,
such as tumor progression (two patients in the in-
tervention group), medical problems (two patients
in the control group), or unwillingness to continue
participation (two patients in the intervention group,
one patient in the control group). Finally, a total of
40 patients (20 patients in the intervention group
and 20 patients in the control group) completed the
study protocol, including follow-up evaluations (Fig. 3).
None of the patients in the intervention group
expressed fatigue or dissatisfaction with the VR-based
therapy. None of the patients in either group reported
significant adverse events associated with the overall
treatment protocol.
Demographic Details
The demographic and baseline characteristics
of the study participants did not differ significantly
between the two groups (Table 1). The mean Korean
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015
version Mini-Mental State Examination scores of

0.0010

0.0019

0.0011
G0.001
G0.001

G0.001
G0.001
0.039
0.347

0.134
the patients were 24.3 in the intervention group and

P
24.6 in the control group. There was no statistically
significant difference.

Primary Outcome: UE Function

The initial motor power and Brunnstrom stage

40.5 (23.5Y49.8)
84.3 (71.1Y93.8)
39.5 (28.1Y46.8)
37.5 (29.0Y47.3)
60.0 (55.0Y64.0)
35.0 (32.3Y35.8)

73.5 (48.3Y85.5)
Control Group (n = 20)

9.0 (7.0Y12.8)
8.0 (6.3Y10.0)

4.0 (2.3Y5.4)
of the affected UE were similar between the two

Post-Tx
groups (median values were 3 for UE motor power
and 4 for Brunnstrom stage in both groups), and
no significant differences were observed in baseline
(pretreatment) BBT, MFT, and FMS scores. The
differences between before and after treatment in
each group were shown in Table 2.
The FMS was subdivided for independent as-

34.5 (16.6Y41.0)
72.2 (62.5Y81.6)
35.0 (21.7Y40.0)
31.0 (18.6Y36.7)
53.5 (44.5Y58.3)
32.0 (30.0Y33.8)

54.5 (38.5Y63.7)
8.0 (7.0Y11.8)
sessment of S/E/F (score, 0Y36), wrist (score, 0Y10),

8.0 (6.1Y9.8)

3.0 (3.0Y4.0)
Pre-Tx
and hand function (score, 0Y14) as well as overall
coordination/speed of the UE (score, 0Y6). In addi-
tion, the MFT was subdivided for independent as-
sessment of S/E/F function (low score, 0Y16) and
hand dexterity (low score, 0Y16). Each subsection of
the MFT was scored on a scale from 0 to 50 (MFT
score in this study = low MFT score  3.125).26

0.0014
The intervention group showed statistically sig-
G0.001
G0.001
G0.001
G0.001

0.048

0.257
0.251

0.052
0.005
P

nificant improvement in the BBT compared with

the control group. In terms of MFT scores, the in-
tervention group demonstrated significant improve-
ment in the S/E/F subsection of the test relative to
TABLE 2 Pretreatment vs. posttreatment parameters in case and control groups

the control group. By contrast, the control group

Intervention Group (n = 20)

38.0 (30.0Y47.3)
82.8 (72.3Y93.8)
39.0 (30.0Y45.1)
38.4 (30.5Y46.5)
58.0 (39.2Y65.5)
34.5 (30.0Y36.0)

showed significant improvement in hand dexterity 70.5 (61.0Y86.3)

8.0 (7.0Y12.6)
7.0 (6.2Y10.0)

4.0 (2.6Y5.6)

relative to the intervention group. In terms of FMS

Post-Tx

scores, the intervention group also demonstrated

significant improvement in the S/E/F subsection of
P by Wilcoxon’s signed-rank test or paired t test with Bonferroni correction.

the test relative to the control group, whereas the

control group continued to exhibit significantly
better performance in the hand subsection of the
test (Table 3).
C/S, coordination/speed; H, hand; Tx, treatment; W, wrist.
30.5 (17.2Y35.5)
70.3 (60.2Y83.6)
33.0 (20.1Y39.8)
33.0 (20.5Y38.6)
52.0 (42.5Y58.3)
31.0 (25.5Y33.0)

52.5 (38.9Y62.8)
7.0 (8.0Y11.8)
7.0 (6.0Y9.8)

3.0 (2.0Y5.1)

Secondary Outcome: Activities of

Pre-Tx

Daily Living
Values are given as median (interquartile range).

There was no significant difference in base-

line (pretreatment) K-MBI scores between the two
groups. Both of the control and intervention groups
demonstrated statistically significant improvements
after treatment in K-MBI scores (Table 2). The changes
in K-MBI score showed no significant differences
MFT (total score, 0Y100)

FMS (total score, 0Y66)

between the two groups (Table 3).

MFT: S/E/F (0Y50)

FMS: S/E/F (0Y36)

FMS: C/S (0Y6)

FMS: W (0Y10)
MFT: H (0Y50)

FMS: H (0Y14)

Differences Between Benign and

Malignant Tumor
Parameter

There were no significant differences in primary

K-MBI
BBT

outcome and secondary outcome between benign

and malignant tumor in each group (Table 4). The

www.ajpmr.com Virtual Reality–Based Rehabilitation on UE Function 455

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 TABLE 3 Comparison of treatment effects between case and control groups
Parameter Intervention Group (n = 20) Control Group (n = 20) P
¸ BBT 11.0 (9.0Y13.75) 8.0 (6.0Y9.8) 0.044
¸ MFT (total score, 0Y100) 11.0 (9.4Y15.6) 12.5 (9.4Y14.8) 90.999
¸ MFT: S/E/F (0Y50) 7.0 (6.0Y9.8) 5.0 (2.3Y6.0) 0.007
¸ MFT: H (0Y50) 4.0 (3.3Y7.8) 7.5 (5.5Y9.5) 0.010
¸ FMS (total score) 6.5 (4.0Y8.8) 7.0 (5.0Y8.8) 90.999
¸ FMS: S/E/F (0Y36) 3.5 (2.3Y4.8) 2.0 (2.0Y2.0) 0.012
¸ FMS: W (0Y10) 1.0 (0Y2.0) 1.0 (0Y2.0) 90.999
¸ FMS: H (0Y14) 1.0 (0Y2.0) 2.0 (2.0Y3.0) 0.046
¸ FMS: C/S (0Y6) 1.0 (0Y2.0) 1.0 (1.0Y2.0) 90.999
¸ K-MBI 15.0 (10.0Y29.5) 16.0 (14.3Y22.5) 90.999
Values are given as median (interquartile range).
P Mann-Whitney U test with Bonferroni correction.
¸ = posttreatment score j pretreatment score.
C/S, coordination/speed; H, hand; W, wrist.

authors compared the two groups within the patients
with benign and malignant tumor. The interven-
tion group showed more improvement in the S/E/F
subsection of the MFT and the FMS, and the con-
trol group showed more improvement in the hand
subsection of the MFT and the FMS in the patients
with benign brain tumor. These findings were also
similar in the patients with malignant brain tumor
(Table 5).
intervention. The patients in the intervention group
improved significantly in proximal UE function, as
assessed by a better score on the S/E/F segment of
the MFT and the FMS as well as enhanced speed of
movement. On the other hand, the patients in the
control group showed more improvement in fine
motor function and overall coordination as assessed
by a better score on the hand segment of the MFT
and the FMS.

DISCUSSION Virtual Reality

The major findings of this study are that VR-
based rehabilitation combined with conventional
OT is better than the conventional OT alone for UE
training in patients with brain tumor. Both groups
had significantly improved UE function over time;
changes in subscore were different according to the
VR has been successfully used to facilitate upper
motor function, which may be related to the enhanced
neuroplasticity observed after VR-based rehabilita-
tion.14,27Y31 The use of VR demonstrates the prac-
ticed, dependent enhancement of the affected arm
by facilitating cortical reorganization.31 As reported

TABLE 4 Comparison of treatment effect between benign and malignant tumor in each group
Intervention (n = 20) Control (n = 20)

Benign Malignant Benign Malignant

Parameter (n = 9) (n = 11) P (n = 11) (n = 9) P
¸ BBT 9.0 (7.5Y12.5) 11.0 (9Y16) 0.266 8.0 (5Y9) 9.0 (6Y11) 0.338
¸ MFT (total score, 0Y100) 9.4 (9.4Y15.6) 15.6 (9.4Y18.8) 0.179 12.5 (12.5Y15.6) 9.4 (9.4Y12.5) 0.179
¸ MFT: S/E/F (0Y50) 9.4 (3.1Y12.5) 6.3 (6.3Y12.5) 0.338 6.3 (3.1Y9.4) 6.3 (3.1Y12.5) 0.226
¸ MFT: H (0Y50) 3.1 (3.1Y6.3) 3.1 (3.1Y9.4) 0.513 6.3 (3.1Y9.4) 3.1 (3.1Y6.3) 0.778
¸ FMS (total score, 0Y66) 5.0 (4.5Y8.5) 7.0 (4Y10) 0.788 6.0 (5Y9) 7.0 (5.5Y8.5) 0.513
¸ FMS: S/E/F (0Y36) 3.0 (2.5Y4.5) 4.0 (2Y6) 0.698 2.0 (2Y2) 2.0 (1.5Y2.5) 0.931
¸ FMS: W (0Y10) 1.0 (0Y2) 1.0 (0Y2) 0.845 1.0 (0Y2) 2.0 (0Y2) 0.597
¸ FMS: H (0Y14) 1.0 (0Y2) 1.0 (0Y2) 0.472 2.0 (2Y3) 2.0 (1.5Y3) 0.841
¸ FMS: C/S (0Y6) 1.0 (0.5Y1.5) 1.0 (0Y2) 0.321 1.0 (1Y2) 2.0 (0.5Y2) 0.472
¸ K-MBI 25.0 (9Y32.5) 14.0 (10Y28) 0.704 17.0 (12Y24) 16.0 (14.5Y21) 0.619
Values are given as median (interquartile range).
P by Mann-Whitney U test.
¸ = posttreatment score j pretreatment score.
C/S, coordination/speed; H, hand; W, wrist.

456 Yoon et al. Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 TABLE 5 Comparison of treatment effects between case and control groups according to tumor type
Benign Tumor (n = 20)
Intervention Control
Parameter (n = 9) (n = 11)
¸ BBT 9.0 (7.5Y12.5) 8.0 (5Y9)
¸ MFT (total score, 0Y100) 9.4 (9.4Y14.1) 12.5 (12.5Y15.6)
¸ MFT: S/E/F (0Y50) 9.4 (6.3Y12.5) 3.1 (3.1Y12.5)
¸ MFT: H (0Y50) 3.1 (3.1Y9.4) 6.3 (6.3Y15.6)
¸ FMS (total score, 0Y66) 5.0 (4.5Y8.5) 6.0 (5Y9)
¸ FMS: S/E/F (0Y36) 3.0 (2.5Y4.5) 2.0 (2Y2)
¸ FMS: W (0Y10) 1.0 (0Y2) 1.0 (0Y2)
¸ FMS: H (0Y14) 1.0 (0Y2) 2.0 (2Y3)
¸ FMS: C/S (0Y6) 1.0 (0.5Y1.5) 1.0 (1Y2)
¸ K-MBI 25.0 (9Y32.5) 17.0 (12Y24)
Values are given as median (interquartile range).
P by Mann-Whitney U test.
¸ = posttreatment score j pretreatment score.
C/S, coordination/speed; H, hand; W, wrist.
in recent studies, whether adding VR programs to
conventional therapy facilitates patient progress re-
mains to be determined.11,27 Piron et al.32 found that
patients with subacute stroke who received supple-
mental VR therapy showed more improvements in
the FMS and the Functional Independence Measure
scale than did patients with subacute stroke who
received only conventional therapy. The results of
Piron and colleagues are therefore similar to this
study’s observations. On the other hand, Crosbie
et al.33 concluded that VR-based therapy had no
significant effect on UE function or activity levels
compared with conventional rehabilitation in pa-
tients with chronic stroke.33 By contrast, Mumford
et al.34 demonstrated that VR therapy (performed
for 1 hr per session for 12 sessions during the course
of 4 wks) in addition to conventional physical ther-
apy improved upper limb motor control in nine
patients with traumatic brain injury. There have
been several studies to clarify the effect of VR-based
rehabilitation on UE function, but reported results
are not consistent.
On this study’s results, VR-based rehabilita-
tion possibly demonstrates significant improvements
especially in the proximal UE. This observation
might stem from the authors’ selection of VR pro-
grams that mostly facilitate proximal UE recovery.
The application of VR programs that instead facili-
tate hand movement and dexterity might consider-
ably alter the results of this study. Conversely, the
patients who received conventional OT showed more
improvements in hand function. This phenomenon
may be a result of fine motor training occupying
one-third of the conventional OT session. For pa-
tients with proximal UE and distal UE dysfunction
www.ajpmr.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Malignant Tumor (n = 20)
Intervention Control
P (n = 11) (n = 9) P
0.065 11.0 (9Y16) 9.0 (6Y11) 0.056
0.186 15.6 (9.4Y18.7) 9.4 (9.4Y12.5) 0.197
0.018 6.3 (6.3Y9.4) 3.1 (3.1Y12.5) 0.026
0.038 3.1 (3.1Y9.4) 6.3 (6.3Y12.5) 0.040
0.535 7.0 (4Y10) 7.0 (5.5Y8.5) 0.639
0.018 4.0 (2Y6) 2.0 (1.5Y2.5) 0.015
0.871 1.0 (0Y2) 2.0 (0Y2) 0.576
0.018 1.0 (0Y2) 2.0 (1.5Y3) 0.041
0.706 1.0 (0Y2) 2.0 (0.5Y2) 0.161
0.450 14.0 (10Y28) 16.0 (14.5Y21) 0.621
of similar degree, the addition of a VR program to
conventional OT will have the advantage of im-
proving overall UE function.
The patients who received VR-based rehabilita-
tion demonstrated improvements in K-MBI scores
that were similar to the control group (21.7 [17.6] vs.
22.1 [19.5]). The authors hypothesize that the lack
of superiority in the intervention group is because
most of the motions in the VR programs primarily
required movements of the shoulder and the elbow.
Common activities of daily life require not only
proximal UE movements but also fine hand move-
ments, such as gripping objects (combs, spoons, and
chopsticks) and fastening buttons. However, shoul-
der flexor, abductor, external rotator, internal rota-
tor, elbow flexor, and extensor were required for
activities of daily living such as washing up, combing
the hair, feeding, dressing, and chair/bed transfer.
The authors thought that VR-based rehabilitation
can be more helpful for these muscle movements
according to the S/E/F score of the FMS and the
MFT. In the current study, VR therapy was con-
ducted in the form of games, with continuous in-
structions and encouragement from the therapist,
accompanied by various background music and on-
going visual and tactile stimulation. The authors
hypothesize that these conditions offered interest,
and patients can more actively participate in reha-
bilitation than conventional OT. The VR program
also provides continuous real-time feedback regard-
ing the patients’ performance, with their scores
displayed on the television monitor or by the ther-
apist. As demonstrated previously,35 these condi-
tions allowed the study participants to immediately
correct any errors of their motion promptly. Taken
Virtual Reality–Based Rehabilitation on UE Function 457
 together, provision of interest, real-time feedback
and task-oriented training, repetition of similar
motions, as well as matching the VR intensity level
with the individual’s abilities all most likely lent
themselves to the recovery of UE motor function by
promoting cortical reorganization.
No adverse events were documented during
the course of this investigation. Most of the par-
ticipants in the intervention group reported that
the VR tasks were easy to understand. Further-
more, the participants indicated their satisfaction
with the conduct of the trial, and only two persons
in the VR group stated that they did not enjoy the
experience. Two patients made complaints about
the composition of the programs used in the treat-
ment session.
Strengths and Limitations of the Study
and Suggestions for Future Research
This is the first study designed to investigate
the effect of VR-based rehabilitation combined with
conventional OT for improving UE function in pa-
tients with brain tumor. The authors recruited pa-
tients with motor power in the affected arm that
was higher than poor grade because patients with
functional level poorer than this cannot capable of
activities within the IREX System and excluded
patients with recurred brain tumor, thus increasing
homogeneity. The authors additionally analyzed the
subsegment of the MFT and the FMS that provided
more detailed information regarding UE function
for each segment.
However, this study has several limitations
for consideration in future studies. First, this study
was not a randomized controlled trial, had a small
sample size, and was unable to determine the long-
term effect of VR therapy. Further randomized con-
trolled trials that include a large number of patients
and long-term follow-up are thus required to fully
evaluate the therapeutic potential of VR for patients
with brain tumor. Second, baseline K-MBI scores
were slightly lower in the intervention group than
in the control group. However, there was no statis-
tically significant difference. Third, cognitive defi-
cits, sensory loss, and other medical issues that
could influence the functional outcomes of this work
were not taken into account in this study’s results.
Fourth, minimum clinically important difference
for each assessment used was not described in this
study. Minimum clinically important difference for
the BBT and the MFT has not been established in
not only patients with stroke but also patients with
brain tumor. Estimated clinically important difference
458 Yoon et al.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
of the UE-FMS ranged from 4.25 to 7.25 points,
depending on the different facets of UE movement
with chronic stroke patients.36 The minimum clini-
cally important difference of the MBI is 1.85 points
in patients with acute stroke.37 Unlike for patients
with stroke, the minimum clinically important dif-
ference of the FMS and the K-MBI has not been es-
tablished for patients with brain tumor. Lastly, none
of the current VR programs in the IREX System
target hand movement, and the glove itself worn by
the patients was recognized by a video camera during
the VR training in this study, so they cannot use
fingers during treatment session. Further studies con-
sidering hand function as well as the development
and use of VR programs targeting hand use are re-
quired for patients with brain tumor.
CONCLUSIONS
The results of the current study demonstrate
that VR-based rehabilitation and conventional OT
are both effective treatments for the improvement
in UE function in patients with brain tumor. VR-
based rehabilitation combined with conventional
OT may be more successful than conventional OT,
especially for the restoration of proximal UE dys-
function. This effectiveness may be applied similarly
to patients with benign and malignant tumor. In
addition to its ample feasibility for application to
patients with brain tumor, VR therapy is safe, well
tolerated, and helpful for functional UE recovery in
patients with brain tumor.
REFERENCES
1. Salander P, Spetz A: How do patients and spouses
deal with the serious facts of malignant glioma?
Palliat Med 2002;16:305Y13
2. O’Dell MW, Barr K, Spanier D, et al: Functional out-
come of inpatient rehabilitation in persons with brain
tumors. Arch Phys Med Rehabil 1998;79:1530Y4
3. Tang V, Rathbone M, Park Dorsay J, et al: Rehabili-
tation in primary and metastatic brain tumours:
Impact of functional outcomes on survival. J Neurol
2008;255:820Y7
4. Greenberg E, Treger I, Ring H: Rehabilitation out-
comes in patients with brain tumors and acute stroke:
Comparative study of inpatient rehabilitation. Am J
Phys Med Rehabil 2006;85:568Y73
5. Marciniak CM, Sliwa JA, Heinemann AW, et al: Func-
tional outcomes of persons with brain tumors after
inpatient rehabilitation. Arch Phys Med Rehabil 2001;
82:457Y63
6. Cole RP, Scialla SJ, Bednarz L: Functional recovery in
cancer rehabilitation. Arch Phys Med Rehabil 2000;
81:623Y7
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 6, June 2015
 7. Marciniak CM, Sliwa JA, Spill G, et al: Functional
outcome following rehabilitation of the cancer patient.
Arch Phys Med Rehabil 1996;77:54Y7
8. Huang ME, Cifu DX, Keyser-Marcus L: Functional
outcome after brain tumor and acute stroke: A compar-
ative analysis. Arch Phys Med Rehabil 1998;79:1386Y90
9. Lam YS, Man DW, Tam SF, et al: Virtual reality
training for stroke rehabilitation. NeuroRehabilitation
2006;21:245Y53
10. Sung WH, Chiu TY, Tsai WW, et al: The effect of virtual
realityYenhanced driving protocol in patients following
spinal cord injury. J Chin Med Assoc 2012;75:600Y5
11. Lucca LF: Virtual reality and motor rehabilitation of
the upper limb after stroke: A generation of progress?
J Rehabil Med 2009;41:1003Y100
12. Mirelman A, Maidan I, Herman T, et al: Virtual reality
for gait training: Can it induce motor learning to
enhance complex walking and reduce fall risk in
patients with Parkinson’s disease? J Gerontol A Biol
Sci Med Sci 2011;66:234Y40
13. Kim BR, Chun MH, Kim LS, et al: Effect of virtual
reality on cognition in stroke patients. Ann Rehabil
Med 2011;35:450Y9
14. Jang SH, You SH, Hallett M, et al: Cortical reorga-
nization and associated functional motor recovery
after virtual reality in patients with chronic stroke: An
experimenter-blind preliminary study. Arch Phys
Med Rehabil 2005;86:2218Y23
15. Fischer HC, Stubblefield K, Kline T, et al: Hand re-
habilitation following stroke: A pilot study of assisted
finger extension training in a virtual environment.
Top Stroke Rehabil 2007;14:1Y12
16. Albert ML: A simple test of visual neglect. Neurology
1973;23:658Y64
17. Han C, Jo SA, Jo I, et al: An adaptation of the Korean
Mini-Mental State Examination (K-MMSE) in elderly
Koreans: Demographic influence and population-
based norms (the AGE study). Arch Gerontol Geriatr
2008;47:302Y10
18. Winstein CJ, Rose DK, Tan SM, et al: A randomized
controlled comparison of upper-extremity rehabili-
tation strategies in acute stroke: A pilot study of
immediate and long-term outcomes. Arch Phys Med
Rehabil 2004;85:620Y8
19. Platz T, Winter T, Muller N, et al: Arm ability train-
ing for stroke and traumatic brain injury patients with
mild arm paresis: A single-blind, randomized, controlled
trial. Arch Phys Med Rehabil 2001;82:961Y8
20. Cuthbert SC, Goodheart GJ Jr: On the reliability and
validity of manual muscle testing: A literature review.
Chiropr Osteopat 2007;15:4
21. Mathiowetz V, Volland G, Kashman N, et al: Adult
norms for the Box and Block Test of manual dexter-
ity. Am J Occup Ther 1985;39:386Y91
22. Nakamura R, Moriyama S, Yamada Y, et al: Recov-
ery of impaired motor function of the upper ex-
tremity after stroke. Tohoku J Exp Med 1992;
168:11Y20
www.ajpmr.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
23. Alonso-Alonso M, Fregni F, Pascual-Leone A: Brain
stimulation in poststroke rehabilitation. Cerebrovasc
Dis 2007;24:157Y66
24. Fugl-Meyer AR, Jääskö L, Leyman I, et al: The post-
stroke hemiplegic patient. 1. A method for evalua-
tion of physical performance. Scand J Rehabil Med
1975;7:13Y31
25. Jung HY, Park BK, Shin HS, et al: Development of
the Korean version of Modified Barthel Index (K-MBI):
Multi-center study for subjects with stroke. J Korean
Acad Rehabil Med 2007;31:283Y97
26. Nakamura R, Moriyama S: Manual Function
Test(MFT) and Functional Occupational Therapy
for Stroke Patients. Saitama, Japan, National Reha-
bilitation Center for the Disabled, 2000
27. Langhorne P, Coupar F, Pollock A: Motor recovery
after stroke: A systematic review. Lancet Neurol 2009;
8:741Y54
28. Saposnik G, Levin M; Outcome Research Canada
Working Group: Virtual reality in stroke rehabilita-
tion: A meta-analysis and implications for clinicians.
Stroke 2011;42:1380Y6
29. Saposnik G, Teasell R, Mamdani M, et al: Effec-
tiveness of virtual reality using Wii gaming tech-
nology in stroke rehabilitation: A pilot randomized
clinical trial and proof of principle. Stroke 2010;
41:1477Y84
30. Henderson A, Korner-Bitensky N, Levin M: Virtual
reality in stroke rehabilitation: A systematic review of
its effectiveness for upper limb motor recovery. Top
Stroke Rehabil 2007;14:52Y61
31. Kleim JA, Jones TA: Principles of experience-
dependent neural plasticity: Implications for reha-
bilitation after brain damage. J Speech Lang Hear
Res 2008;51:S225Y39
32. Piron L, Turolla A, Agostini M, et al: Exercises for
paretic upper limb after stroke: A combined virtual-
reality and telemedicine approach. J Rehabil Med
2009;41:1016Y102
33. Crosbie JH, Lennon S, McGoldrick MC, et al: Virtual
reality in the rehabilitation of the arm after hemi-
plegic stroke: A randomized controlled pilot study.
Clin Rehabil 2012;26:798Y806
34. Mumford N, Duckworth J, Thomas PR, et al: Upper-
limb virtual rehabilitation for traumatic brain injury:
A preliminary within-group evaluation of the ele-
ments system. Brain Inj 2012;26:166Y76
35. Duncan PW, Zorowitz R, Bates B, et al: Management
of adult stroke rehabilitation care: A clinical practice
guideline. Stroke 2005;36:e100Y43
36. Page SJ, Fulk GD, Boyne P: Clinically important
differences for the upper-extremity Fugl-Meyer Scale
in people with minimal to moderate impairment due
to chronic stroke. Phys Ther 2012;92:791Y8
37. Hsieh YW, Wang CH, Wu SC, et al: Establishing the
minimal clinically important difference of the Barthel
Index in stroke patients. Neurorehabil Neural Repair
2007;21:233Y8
Virtual Reality–Based Rehabilitation on UE Function 459