How virtual reality and the metaverse are changing rehabilitation

A patient with balance issues standing on a bosu ball while batting a playful pufferfish between two dapper penguins.

Another seated and holding a weighted ball while kicking at pinball controls with their feet. 

Standing on one foot while following a footpath on a beach; making a ham-and-cheese sandwich in a food cart; playing tarot cards. 

These might all seem odd ways to undergo physical therapy — but this is the future of rehabilitation, enabled by virtual reality (VR) tools. 

“Patients are really engaged with virtual reality,” said Nora Foster, a doctor of physical therapy, physical therapist and Executive Director of NorthBound Health. “The VR immersive experience motivates and challenges patients to get the most out of their rehab therapy.”

Medical device company Penumbra hopes to further enable this capability — and help improve patient outcomes — with the release today of the first hands-free, full body, non-tethered VR rehabilitation platform. 

Penumbra’s REAL System y-Series is the only platform to use upper and lower body sensors that allow clinicians to track full body movement and progress in real time, explained Penumbra CEO Adam Elsesser.

“The full body was the big next step,” said “It’s the one thing in our area that people have been wanting so that they can get working with patients on the rest of the body, not just the upper part, the whole body. It opens up the window to help so many more people.” 

Penumbra’s REAL System y-Series leveraging VR now features upgraded hardware and sensor technology — notably, lower-body sensors. Comprising a headset and five sensors, the technology can now address both upper and lower extremities with a full body avatar, said Elsesser.

It is currently being used in clinics and hospitals across the U.S. for patients undergoing physical, occupational and speech therapy, explained Elsesser. It helps to address upper body impairments caused by stroke and other conditions, core and balance, cognition, functional uses, activities of daily living training (grocery shopping, self-care) and cognitive stimulation.

The REAL System y-Series is intended to be used with a therapist that guides patients’ movements, said Elsesser; they can view on a tablet what the patient is seeing in virtual reality. Clinicians can then customize exercises and activities to challenge, motivate and engage patients, while tracking movement and progress in real time.

But, Elsesser was quick to emphasize that this is “not just a game that we’re repurposing. It’s very particularly healthcare oriented. The experiences and activities done in VR are designed with very serious clinicians.” 

Also, while the metaverse is undoubtedly one of the hottest topics in tech — if not the free world — right now, he underscored that the product is called “Real System” for a reason. 

People utilizing avatars in the emerging metaverse environment to attend unique virtual events not possible in the real world, wear virtual clothes, buy virtual goods and have experiences they would otherwise never be exposed to is all well and good, he said — but in this case, the virtual world is being used for helping people get back to the real world. 

“We don’t want people to live in a fake world,” said Elsesser. We’re a healthcare company, we want people to get better and return to their daily lives. This just happens to be a tool that is particularly well suited to do that.”

Overcoming rehabilitation challenges

The prevailing sentiment is that the need for innovative rehabilitation therapy has never been greater. For instance, in a YouGov survey of more than 100 U.S.-based physical therapists, 80% of respondents said the field has changed only moderately or not at all over the last decade.

Similarly, nearly 75% say that patient compliance is the biggest challenge in physical therapy today, and more than half believe that VR can help improve that.

And, while the majority of physical therapists (65%) would be eager to use technologies like VR in their practice, only 39% believe their hospital and clinic decision makers are likely to invest in such technologies.

Foster and others agree that two of the largest challenges to overcome in rehabilitation are maintaining patient motivation and lack of engagement. 

VR can help with this in a variety of ways, Foster said. For instance, patients who are dealing with pain are often reluctant to move and challenge themselves. But, when that patient puts the VR system on, they move in ways that they haven’t before (or haven’t for in a long time). 

From a mental health perspective, meanwhile, a patient with a spinal cord injury or a brain injury oftentimes can’t physically do things or go to places — which is understandably frustrating. VR allows them to forget these circumstances for a while, said Foster.

“Having access to this specialized equipment, I am able to engage and motivate my patients with activities that are fun and enjoyable,” said Foster, who has used the REAL system for a range of injuries and conditions. 

She pointed specifically to one patient who found typical rehab activities difficult and eventually gave up on therapy altogether. But when therapists showed him REAL and the various activities, “he felt really involved, leading to participation in therapy again,” she said. In fact, “he just loves it.”

And, as patients progress, settings can be adjusted to keep them engaged, said Elsesser. Therapists have data in a way that’s hard to measure and see when just watching someone. 

The use of VR increases satisfaction for therapists, too, he pointed out. “They love watching their patients being more engaged.” 

Gaming roots

As Elsesser explained, he and Arani Bose founded Penumbra in 2004 initially with a focus on stroke patients. The company is most well-known for its interventional technology for blood clots causing strokes. “At the time, that was pretty out there technology,” said Elsesser. 

The company has since moved to technologies addressing conditions in other parts of the body, and started its trajectory to VR technologies just five years ago (and rather by chance). In 2017, Elsesser said, he was invited to demo SixSense gaming technology. 

He was initially reluctant, he said, but he went anyway, and described being in the midst of a game standing on top of a castle wall and thwarting attackers. Suddenly, two other players yelled over the noise of the game that he should close his eyes. 

He didn’t. “I wanted to see what I wasn’t supposed to see,” he said. 

It turns out a headset glitch caused the VR castle floor to turn into a bright white nothingness. As he explained, even though he intellectually knew that it wasn’t real, he nevertheless had a physical reaction. 

The benefits for healthcare became very obvious, he said, likening VR’s ability to trick people to neuroplasticity (when the brain rewires itself based on internal and external stimuli).

“It’s been a great journey to get here,” Elsesser said of today’s release. “We just can’t wait to hear the individual stories that patients are going to be able to share, tell us how they’re feeling better, doing better, returning to a more normal life.”