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Stroke affects 15 million people annually, with 55-75% of survivors experiencing motor impairments and lower quality of life. These deficits, including fine motor skills, motor control, and dual-task coordination, significantly impact independence and quality of life.

Virtual reality (VR) systems were developed to aid in motor recovery, allowing users to interact with a multisensory simulated environment and receive real-time feedback on performance. Virtual reality systems offer a unique approach to rehabilitation, incorporating neuronal and motor learning theories. These systems allow users to feel invested in their recovery and incorporate tasks, repetition, and adjustable difficulty levels. These systems also offer the option to have a VR teacher complete activities, stimulating mirror neurons and enabling "learning by imitation." The VR system provides real-time performance feedback based on results or multiple trials, enhancing learning. Studies show its impact on learning, enabling customized training sessions for patients to practice actual skills, thereby enhancing their learning experience.

Advantages Of Virtual Reality In Rehabilitation For Stroke Patient:

1. Neuroplasticity: VR training shows evidence of promoting neuroplasticity, leading to functional recovery.

2. Contralateral Motor Activation: Post-VR training, stroke patients experience a shift in motor activation from the contralesional to the ipsilesional hemisphere.

3. Enhanced Motor Activation: Discordant visual feedback in VR causes greater activation of primary motor regions than non-discordant feedback.

4. Recruitment of Affected Motor Regions: Discordant feedback and mirror feedback recruit the affected primary motor region, enhancing motor control in stroke patients.

5. Engagement and Motivation: Recovering from a stroke has a lot to do with relearning old or learning new skills. VR provides therapeutic opportunities in a variety of visual and auditory environments.

6. Safety and Flexibility: VR provides a safe, easily manipulated environment that can be adjusted and tailored to meet the patients’ need and progress.

7. Increased Therapy Frequency: VR can be used without direct supervision, allowing more frequent therapy sessions compared to traditional supervised physiotherapy.

9. Build Confidence: VR can help you practice necessary exercises without fear of judgment or injury by providing a safe and supportive environment.

10. Accessibility & Convenience: VR rehabilitation can be done in clinics, hospitals, or at home, making it accessible to patients with mobility challenges or those far from clinics.

The methods and applications of virtual reality (VR) in the field of physiotherapy vary widely because this technology is still very new. It takes a computer with a special graphics system to generate a virtual reality experience. Both the device's hardware and software can be configured to simulate and give subjects feedback in a virtual setting.

8. Improvement in Functional Abilities: Commercial video game-based VR therapy has shown improvements in balance, postural control, functionality, ADLs, and quality of life. A therapist must decide whatever kind of virtual reality (VR) technology to employ with their patients before integrating VR into rehabilitation.

The two styles that are most frequently utilized in rehabilitation:

1. The immersive style of VR: which is usually administered via a head-mounted device, immerses the viewer in a lifelike setting.

Examples of VR immersive exercises include:

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Punch the boxer: Image1, Is one of the VR games designed specifically for stroke patients. This gauges the patient's ability to keep an eye on their body's equilibrium and records their arm reach. The patient is battling a virtual boxer in this game. Reaching a predetermined number of points at a predetermined time or knocking out the opponent are the two ways the patient attempts to win the round. Both the VR controllers and the backdrop sound effects tremble when the opponent is hit.

Throwing the ball in the dragon’s mouth: The patient's task in this game is to simply toss the ball into the dragon's mouth. At varying speeds, the dragon's mouth opens and shuts. The patient may or may not be close to the dragon's mouth. Among the difficulty levels are a random spike appearance or a fire explosion in the center of the ball and the dragon's jaws. The patient needs to make the right decision and toss the ball into the dragon's mouth.

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Opening and closing the tap: This examines the patient's wrist movements. The patient must hold the tap and turn it in a clockwise direction to open it. In the same way, he or she must rotate his wrists counterclockwise to close it.

Paper cutter VR: This easy practice can help you become more accurate. The patient is asked to use a paper cutter to cut out a random drawing. Any hand can hold the paper cutter, and the design appears on the screen at arm's length. The screen also displays the drawing that is intended to be cut out of the original drawing. The final drawing must be formed by the patient's hand movements. The degree of precision likewise rises with difficulty. Image 2

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Beat Saber: Image2, In this game, the player cuts blocks that are offered from various locations while listening to music while wielding a lightsaber in each hand. To lessen the chance of sensory overload, the music and special effects could be turned down a bit, and the game's difficulty can be changed across a wide range. People with restricted finger motions may play this game because it didn't require the capacity to press any buttons. Although it could be played while sitting, the game was intended to be played standing.

Non-immersive style of VR: This subset of VR usually takes the shape of a video game console. Although these technologies are less expensive, they don't produce the same degree of environmental engagement as immersive systems.

2. Non-immersive style of VR: This subset of VR usually takes the shape of a video game console. Although these technologies are less expensive, they don't produce the same degree of environmental engagement as immersive systems.

Examples of the non-immersive VR exercises:

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The game of choice: Image3, Causes motor demands on the patient's upper and lower extremities since they must kick the football or stretch left and right to block the net which activates quadriceps and the hamstrings muscles. This illustration shows how many different types of VR games are available for rehabilitation, as well as how flexible, adaptive, and adaptable the tasks are, Also fatigue must be controlled.

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C-Mill: Image4, Is one example that replicates real-world situations and difficulties encountered in daily life in a secure and cozy setting. It evaluates and trains gait and balance using force plate technology. Additionally, it offers task-specific balancing and gait training, objective evaluation, and real-time performance feedback. And We may ask the patient different requests to activate different muscles, such as lifting a stone from the virtual path to use the muscles of the upper body .

Another VR exercises:

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Image5, It is preferable to use virtual reality like the one in the picture, so that the movement is modified with rhythmic music to stimulate a greater number of sensors and a small ball is used, so we lure him to do the PNF technique.

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Image6, Through the position shown in the picture, we can do back and Hamstring and buttock strength exercises. It is preferable to use games or music to interact with the movement and swaying of the device to learn balance and trunk control.

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Image7, Virtual reality also allows as much as possible to restore fine movement and wrist muscle movement by simulating a piano and imitating movements.

Disadvantages of virtual reality in stroke rehabilitation:

Virtual reality offers a lot of advantages when it comes to stroke rehabilitation, but there are also drawbacks because it uses modern technology. These include cost concerns, problems with the human-computer interfaces it uses, which can be uncomfortable for novice users, problems with immersion that could affect the effectiveness of the rehabilitation process, and potential compatibility problems between different devices. Virtual reality systems typically process large amounts of data, necessitating processing and storage capacity. They also face challenges related to therapists' lack of computer skills, infrastructure deficiencies, expensive equipment initially, poor communication (for telerehabilitation in rural areas), and patient safety concerns.

Side Effects of Virtual Reality in Stroke Rehabilitation:

While virtual reality (VR) has shown promise in stroke rehabilitation, there are potential side effects that need to be considered. These include:

Physical Side Effects:

• Motion Sickness: This is a common side effect, especially when users are exposed to rapid movements or disorientation within the virtual environment. It can lead to nausea, dizziness, and headaches.

• Fatigue: The physical effort required to interact with VR environments can lead to fatigue, especially in patients with limited mobility.

• Exacerbation of Symptoms: In some cases, VR can exacerbate symptoms such as dizziness or balance problems, particularly if the user is not accustomed to the technology.

Psychological Side Effects:

• Anxiety or Discomfort: Some users may experience anxiety or discomfort due to the immersive nature of VR. This can be particularly problematic for individuals with preexisting mental health conditions.

• Overreliance on Technology: There is a concern that excessive reliance on VR for rehabilitation could hinder the development of real-world skills and social interactions