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Welcome to Cybertherapy

January 1, 2011
by Randolf Palmaira, PT, MS, MSA, LNHA
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Virtual rehab improves patient results

Did you know that a staggering 69% of the world's almost seven billion people play video games where players of all ages enter a virtual environment to match wits against an avatar?

Did you know that for more than 10 years, therapists have been using virtual environments to treat phobias such as fear of heights and public speaking, as well as addictions, including alcohol and drugs? Were you aware that the U.S. Army uses virtual environments to treat soldiers with post-traumatic stress syndrome?

It may not come as a surprise that short-term, subacute rehabilitation centers around the country have also jumped on the cybertherapy bandwagon. And the initial results seem quite promising.

A few years ago, I was doing some research on innovative techniques that could be used to treat stroke patients in conjunction with traditional modalities. There were at least four “absolutes” that I felt any new program would need to include. The first was that the therapist had to have the ability to control the variables for focused treatment sessions. The second, the patient's progress would need to be quantifiable. The third, there had to be a “fun factor” to encourage patients to immerse themselves in their therapy. And, lastly, the cost would need to be modest and affordable.


After reviewing numerous systems, I decided on the Interactive Rehabilitation and Exercise System (IREX), which places the patient in a computer-generated game environment and allows for isolated joint movement, combined joint movement, and full body functional movement for upper and lower extremities. In this system, the clinician is able to tailor and manipulate the session, thus ensuring greater focus on the patient's needs. The therapist sets parameters including range of motion (0-180 degrees), level of intensity (1-10), and selects body parts that should be stimulated during the session including the frontal and sagittal planes.

Additionally, to stimulate and encourage the patient, the therapist can preset individual exercise games for a bell to sound if and when a patient reaches a functional target for a specific muscle group. The sophisticated monitoring system uses a deflection mode which determines the amount of force exerted by the patient and tracks the eccentric and concentric phase of movement.

In the latter part of 2008, we introduced this virtual exercise and gaming program at the Center for Nursing and Rehabilitation (CNR), located in Brooklyn, New York. We were the first healthcare organization in New York City to implement virtual rehabilitation. CNR is a member of the Beth Abraham Family of Health Services, which is a not-for-profit healthcare organization, and one of the largest long-term care service providers in New York State.


Randolf Palmaira, PT, MS, MSA, LNHA
Randolf Palmaira, PT, MS, MSA, LNHA

The system includes approximately 20 preloaded games and activities that are designed to improve physical strength, balance, coordination, cognition, and executive functioning. Through patient interaction with on-screen objects such as soccer balls, drums, and birds, patients work through a clinician-controlled exercise program.

During the activities, patients watch themselves exercising on large monitors, in real time, and listen to upbeat music and the sounds correlating to the objects seen on screen. For example, when patients see large, colorful balloons floating in the air and are instructed to stretch in order to catch and burst the balloons, they hear popping sounds with each successful burst. While this is occurring, the therapist may be correcting the patient's movements so they can achieve greater success. Patients can repeat the same exercise or move on to another activity, as directed by the clinician.

At the end of each rehabilitation session, the patient and therapist review the patient's performance, compliance, and kinematic data, which have been recorded by the system's camera technology, and can be viewed on the monitor or as a printout. This immediate feedback has proven to be encouraging and motivating for the patient and the therapist alike.

At the next scheduled virtual rehab session, the therapist reviews the results from the previous session with the patient and sets new goals for future sessions. The continuity of treatment shows progress and re-establishes goals.


The famous playwright, George Bernard Shaw, said that “We don't stop playing because we grow old; we grow old because we stop playing.”

Well, this exercise system brings out the kid in all of us. The attractive and colorful 2-D graphics used in the many games included in this system produce the illusion of immersion in a real environment rather than a virtual one. Each “game” or exercise activity has all the bells and whistles needed to stimulate visual and auditory modalities in addition to kinesthetic and tactile senses.

Some of the most popular exercise games among our patients have turned out to be driving a race car around an Indy track, kicking soccer balls into a net, tapping on sets of drums, and snowboarding. Games, which run for approximately 30 seconds to five minutes each, are selected by the patient and therapist based on the areas of the body that need focused and repetitive exercise. As the patient is involved in his or her on-screen activity, the therapist observes the patient's movements on the large plasma screen, watching for fluidity and smoothness of movement, postural imbalance, and adjusting the patient's movements as needed during the exercise activity.