The use of the computer assisted rehabilitation environment in assessment and rehabilitation

The use of the


Introduction
In the field of medicine and rehabilitation, the search for innovation is a dynamic process for the sake of finding tools to help diagnose and treat different bodily conditions. The use of virtual reality in medicine and rehabilitation has a promising and effective influence although most of these technologies are expensive and are not ubiquitously available [1,2]. Virtual reality has been studied as an assessment and rehabilitative tool [3][4][5]. A systematic review by lee et al [6] concluded that virtual reality training was effective in improving function in patients with chronic stroke. Similarly, Gumaa and Rehan [7] found the current evidence in support of virtual reality as an effective tool in orthopedic rehabilitation. Moreover, several systematic reviews have suggested the use of virtual reality in rehabilitation of different conditions, such as Parkinson's disease [8,9], multiple sclerosis [10,11], burn [12], low back pain [13], total knee arthroplasty [14,15], functional ankle instability [16] and breast cancer [17]. Additionally, a recent study by Rodrigues et al [18] concluded that a single session of virtual reality could improve shortness of breath, tiredness, and anxiety in patients hospitalized with Coronavirus Disease-2019 .
One of the most advanced virtual reality technologies is the computer-assisted rehabilitation environment. Created by Motek Medical (Motekforce Link, Amsterdam, the Netherlands) in the early 2000, the computer-assisted rehabilitation environment system is a fully immersive type of virtual reality that has been used for assessment, rehabilitation, and research purposes for healthy populations and different orthopedic, psychological, neurological, and vestibular conditions [19]. The creator of the computer-assisted rehabilitation environment system called it "the world most advanced biomechanics lab". The computer-assisted rehabilitation environment system is a result of the integration of many modalities in one system, such as virtual reality, treadmill, biomechanical and physiological biofeedback. In addition to performing functional activities in a fully immersive virtual reality environment, the computer-assisted rehabilitation environment system allows real-time feedback to analyse these activities. It provides a controlled environment that maintains patient safety and can be customised to patients' needs [20]. A motion capture system, with base platform and force plate describe the basic components of the computer-assisted rehabilitation environment system. The base platform is operated through a hydraulic and mechanical mechanism that allows the base to move up to six degrees of freedom. A threedimensional motion capture system with around 12 cameras captures the subject's performance. The patient can be situated in front of a big flat, curved panoramic screen, or inside a dome. The operator can provide perturbation to the platform according to the complexity of the task. There are various modifications and additions to the basic when needed. Treadmill can be incorporated into the system and the degree of virtual reality immersion can be modified with different gaming applications depending on the target treatment goals. Real-time movement tracking is available to show subjects' performance and provide immediate feedback.
A safety harness is also available to provide the necessary support. A customized D-flow software operating the system enables the operator to adjust and change specification of the gaming applications used. Although biofeedback-driven equipment is many, when the concept of biofeedback is incorporated into an upscale technology such as the computer-assisted rehabilitation environment system, the result can be very promising. The force plate in the computer-assisted rehabilitation environment system can provide real-time feedback to both the patient and the operator and can also show postural control strategies the patient is using during the task [20]. The purpose or this study was to review and analyze the available literature regarding the use of the computer-assisted rehabilitation environment system in assessment and rehabilitation.

Search strategy and selection criteria
In this review, we searched PubMed, Web of Science, Cochrane Library, Scopus, and Physiotherapy Evidence Database databases from inception to October 2021. We used the search term "computer assisted rehabilitation environment". Mendeley was used to identify and exclude duplicate articles. Then, title, abstract and full-text screening was performed. Articles addressing the computerassisted rehabilitation environment system in any way were included in this review. Conference proceedings, reports of abstracts only and papers in languages other than English were excluded.

Results
Our search retrieved 205 articles, with 119 duplicates identified and removed. After screening 86 articles and excluding irrelevant results and conference proceedings, we included 50 relevant articles which directly or indirectly addresses the computer-assisted rehabilitation environment system and were published in scientific journals.

Discussion
In this review article, we reviewed the available literature to find out how the computerassisted rehabilitation environment system was used in assessment and rehabilitation. Although the computer-assisted rehabilitation environment system technology is expensive and usually found in big rehabilitation centers, hospitals, research, and military facilities, this technology helps in assessment and rehabilitation of different bodily conditions thanks to the innovations and the accessories attached to the machines [19,59]. Although we found 50 studies addressing the computer-assisted rehabilitation environment system, research is still lacking. This may be due to the lack of availability of the computerassisted rehabilitation environment system due to the high cost and the bulky infrastructure required for the system.
When a subject uses the computer-assisted rehabilitation environment system for assessment or treatment, their performance can be challenged through the movement of the movable platform in six degrees of freedom, incorporating additional accessories to the main setup of the system, or through increasing the complexity of the task by the operator through changing the speed of the task or the surface platform parameters (speed, perturbation, inclination, etc.). After the patient's performance is fed to the computer and simulated on a human body model, performance accuracy, errors and parameters can be calculated and fed back to the big screen for real-time feedback [20].
Challenging patient's performance can also be performed by adding a second task in addition to the primary targeted task. Kizony et al. [69] used a gaming application which allows the patient to virtually shop for groceries while virtually walking to select their shopping items. They investigated what effect a single task such as walking or dual tasks such as walking and selecting the grocery items have on gait parameters in patients with stroke as compared to healthy controls. As expected, there was variability in gait parameters between the two groups with the stroke group walked slower with dual tasking which had more cognitive demands.
A systematic review by Collins et al [19] was conducted on the use of the computer-assisted rehabilitation environment system in research and rehabilitation. They found 31 articles published on the computer-assisted rehabilitation environment system from 1999 to 2013, 9 of them were conference proceedings. Less than half of them (12 papers) studied the use of the computer-assisted rehabilitation environment system in rehabilitation. The published studies included subjects with amputations, cerebral palsy, traumatic brain injuries, stroke, vestibular dysfunctions, gait, and balance abnormalities. Since the technology is primarily found in military facilities, a lot of studies have been conducted on active service member, off duty military personnel with or without medical conditions.
Young et al. [21] attempted to identify how humans control dynamic walking stability when exposed to platform and visual anteroposterior and mediolateral oscillations. Participants walked in the computer-assisted rehabilitation environment system with a 7-meter diameter dome and a virtual scene of 300° field of view. six-degrees of freedom platform with treadmill was embedded in the bottom of the dome. The computer-assisted rehabilitation environment system was used to produce physical or visual oscillations during walking and to measure their effect on margins of stability. A 24-camera Vicon motion capture system at 60 Hz and 22 reflective markers were used for data collection. The study concluded that anteroposterior margin of stability for anteroposterior platform oscillations, Mediolateral platform oscillations and mediolateral visual oscillations were smaller than during no perturbation. Mediolateral margin of stability was larger during all perturbation conditions than during no perturbation.
Gholizadeh et al. [25] used the computerassisted rehabilitation environment system to assess dynamic postural stability when recovering from sudden anteroposterior trip perturbations during walking. Center of Mass, peak trunk angular velocities, Whole-body angular momentum, step width, and stance time were measured during walking in different arm and walking conditions. Healthy young participants walked on the computerassisted rehabilitation environment system treadmill in symmetric and asymmetric walking conditions simultaneously with three different arm swings conditions: normal arm motion, arms were bound at their sides and participants were instructed to walk without arm swing. Treadmill speed was 1.2 m/s speed for both legs in the symmetric condition and 1.2 m/s for left leg and 0.96 m/s for right leg in the asymmetric condition. A set of 57 reflective markers was used to analyze gait parameters before and after recovering from perturbations. This study indicated that anteroposterior trip perturbation, arm conditions and Walking conditions had an influence on dynamic postural stability by affecting various gait parameters. Arm movements could help in recovering after perturbations.
Shafelty et al. [35] used the computerassisted rehabilitation environment system as an assessment tool to measure ground reaction force and angle range of motion in two versions of the 3D printed Compliant and Articulating Prosthetic Ankle and to compare them to two other types of prostheses: the Solid Ankle Cushioned Heel foot and the Renegade® all terrain prosthetic foot. Ten ablebodied participants wear a transfemoral prosthetic simulator and walked the the computer-assisted rehabilitation environment system treadmill system for gait analysis. Shafelty et al. concluded that the ground reaction forces and ankle angles of the Compliant and Articulating Prosthetic Ankle foot during gait cycle were greater and more closely to normal gait than the solid ankle cushioned heel foot and Renegade® all terrain prosthetic foot.
Streicher et al. [35] reported that the computer-assisted rehabilitation environment system is a safe and effective tool for gait and balance training in multiple sclerosis patients. They compared the use of the computer-assisted rehabilitation environment system with traditional physical therapy on Berg Balance Scale, Timed Up and Go test, 6-Minute Walk Test and Timed 25-Foot Walk. While the computerassisted rehabilitation environment system group showed significant improvements for all outcome measures, traditional physical therapy group showed significant only in Berg Balance Scale. Further, in a case study by Rábago et al. [46], the computerassisted rehabilitation environment system was used for assessment and rehabilitation of a case with mild traumatic brain injury who successfully returned to full duty and training for combat deployment. Another case report by De Luca et al. [46] showed the efficacy of the computer-assisted rehabilitation environment system in improving cognitive and Health, sport, rehabilitation Health, sport, rehabilitation Здоров'я, спорт, реабілітація Здоров'я, спорт, реабілітація Здоровье, спорт, реабилитация Здоровье, спорт, реабилитация 2023 9 (2) psychological status in post-stroke individuals. Additionally, Rachitskaya et al. [46] reported that using the computer-assisted rehabilitation environment system as a visual rehabilitative tool for retinal prostheses recipients could improve ability to use the Argus II while performing functional tasks.
The available evidence suggests that the computer-assisted rehabilitation environment system may be a promising rehabilitative tool for several conditions. The computer-assisted rehabilitation environment system is a fully immersive type of virtual reality which is more advanced than other non-fully immersive tools. Therefore, it is predictable that the computer-assisted rehabilitation environment system would be effective as the other types of virtual reality which have been supported by evidence based on large number of studies [6][7][8][9][10][11][12][13][14][15][16][17][18]. However, studies using the computer-assisted rehabilitation environment system in rehabilitation are limited in number, had a small sample size or in the form of case studies which limit the generalizability of the findings. Therefore, further high-quality studies are needed to confirm the efficacy of the computer-assisted rehabilitation environment system and compare it with traditional interventions and other types of virtual reality to investigate the costeffectiveness of this high-cost technology.
The computer-assisted rehabilitation environment system provides an excellent rehabilitative environment. However, the high cost may be the restriction to use in research purposes and clinical practice. Great technologies sometimes come with some disadvantages. The computerassisted rehabilitation environment system is bulky, requires a large space and sophisticated housing infrastructure limits its versatility. Additionally, the technology is expensive and almost only available in government-run, military, or large-funded organizations/facilities. Moreover, the movable platform has limited functionality in challenging balance of human being because the movement happens around pre-defined axes which are close to the surface of the platform and thus has limited challenge tasks to the proximal joints. Also, it does not allow isolated joint perturbation since it is not designed for that purpose, making compensatory strategies difficult to be quantified [20,58,59].

A personal experience with the computerassisted rehabilitation environment system
The first author of this review had a chance to work among a team of healthcare providers and used the computer-assisted rehabilitation environment system in rehabilitation of patients with different pathologies. Out of a personal experience, I can say that the computer-assisted rehabilitation environment system is an interesting, engaging, and motivating tool of rehabilitation. Usually, when we see a fancy technology, we are intrigued to see what it can do. When we explained what the computer-assisted rehabilitation environment system technology can do to patients, they were encouraged to try it out. One patient with a stroke said, "I want to focus and accomplish one task in the the computerassisted rehabilitation environment system so I can be a stroke survivor rather than a stroke victim". This pushed the patient to do her best to get high scores in one of the physically challenging gaming applications.
Another patient with scoliosis wanted to see if she can activate her back muscles to correct the scoliotic curve using the "Maze" gaming application. We used a therapeutic bag filled with water called "aqua bag" and asked the patient to carry it over her shoulder, hold it with both hands and navigate through the maze she sees in the big screen in front of her. We adjusted the game difficulty to selectively activate the stretched back muscles, hoping that with repetitive activations, the patient will get into the habit of activating the desired muscles in normal daily activities. The fact that the computer-assisted rehabilitation environment system allows the use of different rehabilitative tools either installed on the machine or even attached to the patients, this can make the exercise performed more creative.
There are many ways to increase the difficulty of the task using the computer-assisted rehabilitation environment system which makes the computer-assisted rehabilitation environment system effective also in the athletic population. We used it with weightlifters, runners, golfers, and tennis players. Of course, those population has different goals in rehabilitation, and we had to be creative in individualizing the exercise tasks. For example, we incorporated the use of an ankle destabilizing device for an athlete recovering from an ankle sprain and asked the patient to use the "car racing" gaming application. Using this application, the patient had to virtually race with a car and avoid being hit from other cars in the track. By balancing on the injured ankle with a destabilizing device while we control Health, sport, rehabilitation Health, sport, rehabilitation Здоров'я, спорт, реабілітація Здоров'я, спорт, реабілітація Здоровье, спорт, реабилитация Здоровье, спорт, реабилитация 2023 9(2) the difficulty level of the platform movement while trying to get high scores in the application, we can achieve the rehabilitation goals and prepare the athlete for sports participation.

Conclusion
The computer-assisted rehabilitation environment system provides an excellent assessment and rehabilitation environment. The high cost and the bulky infrastructure, however, may be the restriction to use in research purposes and clinical practice.