Welcome to Cybertherapy

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

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.

For example, virtual snowboarding has been a popular activity for patients with joint replacements. While this activity focuses on the full body, the clinician can direct the patient to bend forward and backward, laterally bend the spine, step forward/backward and side to side, and rotate the spine. Trunk movements are used to steer the snowboard. Contrast this computerized gaming activity with a traditional exercise for hip replacement patients of stepping up and down on a staircase. Which activity would you prefer?

As patients progress at one level, they will be transitioned to more difficult tasks. For example, successful weight shifting from left to right would transition to swaying left to right. Achieving higher levels increase speed of movement and complexity of task. Through specific computerized games, wheelchair patients are encouraged to bend forward and pick up items. Moving up from one level to the next gives patients confidence and encouragement which directly transfers to their ability to perform the real-life activities of daily living.


Anyone requiring traditional rehabilitation can benefit from virtual rehabilitation. Our patients have had neurologic affectations, cardiovascular, orthopedic conditions; or debilities including stroke, Parkinson’s disease, multiple sclerosis, musculoskeletal disorders, amputations, joint replacements, fractures, and brain injuries. They have ranged in age from 20s to 80s and have been low- to high-functioning adults.

The length of treatment for the virtual rehabilitation program is generally two to six weeks, depending on a patient’s progress and goals. Sessions last from 15 minutes to one hour based on a patient’s tolerance and goals.

While there is a definite comfort level for quantifying results in any therapeutic rehabilitation situation, in this case there are numerous intangible benefits.


While there is a definite comfort level for quantifying results in any therapeutic rehabilitation situation, in this case there are numerous intangible benefits. For example, you can’t quantify a patient’s level of enjoyment during their sessions or that there is a greater level of compliance to treatment because the patient is having a good time. You can’t quantify a patient’s improved self-esteem and self-confidence derived from receiving immediate positive feedback. And you can’t quantify results from avoiding cross-contamination because the system is touch free and operates only on gestures or that patients are distracted from feeling pain. But there are tangibles you can quantify and these benefits include:

  • Improved balance, coordination, and strength

  • Improved cortical reorganization

  • Enhanced executive functioning and cognitive ability

  • Increased therapeutic output and muscular capacity

  • Flexibility of individualized and graded therapeutic treatment protocols (gradual increase of intensity from level 1-10, range of motion from 10-180 degrees)

  • Capacity to objectively measure and record performance

Joseph Chavez, PT, CNR, and a patient are shown on a display screen engaging in a virtual rehabilitation exercise.


Below are some of the intangible and tangible drawbacks to introducing a computerized virtual rehabilitation program:

  • Technology gap. The resistance of patients to adapt to technological advances into their everyday living. For that matter, some clinicians also have a block against jumping on the technology bandwagon.

  • Clinical acceptance. Therapists question the efficacy of computerized therapeutic gaming program.

  • Cybersickness or simulator sickness. Nausea can result when there is a conflict between perceptions in one’s senses.

  • Space and cost. The initial installation for our system included the GestureTek computer system, LCD ceiling-mounted projector, flat-screen television monitor (32′ by 40′), and green mat and screen which is required for the camera to capture the virtual environment. In 2011, the IREX system will be upgraded to 3-D from 2-D alleviating the need for the green screen technology. The cost for the installation and equipment starts at $20,000.


After analyzing and comparing data at CNR from our stroke and amputee patients during 2009 and 2010, we have found that stroke patients returned home to an active lifestyle four days earlier compared to patients who were not participating in the virtual rehabilitation sessions. Amputee patients returned home three days earlier than patients with the same disability who did not use the virtual rehabilitation program.

Other subjective observations from therapists include that patients seem to be more engaged during their sessions. Because they are having fun, patients are more motivated to work longer and harder.

So based on patient and therapist enthusiasm and preliminary statistical results, within a year of integrating this system with our traditional therapeutic rehabilitation program, we began expanding the virtual program to other long-term care facilities within the Beth Abraham Family. In addition to Center for Nursing and Rehabilitation, we now have virtual rehabilitation programs at three of our other New York facilities: Beth Abraham Health Services in the Bronx, Margaret Tietz Nursing and Rehabilitation Center in Queens, and Schnurmacher Nursing and Rehabilitation Center in White Plains. And, we are considering expanding the computerized gaming system into some of Beth Abraham’s Adult Day Health Care Programs and at our Comprehensive Care Management Day Centers, which offer rehabilitation therapy.

Patients have a great time watching themselves on a large plasma screen during therapeutic work sessions using the interactive virtual rehabilitation exercise program.

Joseph Chavez, PT, CNR, uses virtual rehabilitation to help a patient improve her standing tolerance, balance, and coordination.


Introducing virtual rehabilitation into traditional rehabilitation centers motivates, encourages, and rewards our patients by improving their quality of life in a shorter period of time-and allows them to have fun, too. LTL

Randolf Palmaira, PT, MS, MSA, LNHA, is Executive Director of the Center for Nursing and Rehabilitation, CNR, a member of the Beth Abraham Family of Health Services, a not-for-profit organization, and one of the largest long-term care service providers in New York State. He can be reached at

rpalmaira@bethabe.org or (718) 636-1000, ext. 403. Long-Term Living 2011 January;60(1):32-37

Topics: Articles , Rehabilitation , Technology & IT