Virtual Reality in TBI Rehabilitation: A Neuro Rehab PT’s Perspective

March is Traumatic Brain Injury (TBI) Awareness Month, a time dedicated to raising awareness about brain injuries and advancing research and treatment approaches that help patients recover. As a neuro rehab physical therapist, I’ve worked closely with TBI patients and have seen firsthand the challenges they face in regaining independence. Rehabilitation is never one-dimensional—it requires an integrated approach that addresses motor recovery, cognitive function, and balance control all at once.

This Wednesday, I wanted to highlight the role of virtual reality (VR) in TBI rehabilitation, an area of research that is rapidly growing and showing exciting potential for improving recovery outcomes. VR has become an increasingly powerful tool for engaging patients, increasing therapy intensity, and providing functional, real-world training in a controlled environment. But how effective is it? And does immersive VR (fully interactive, headset-based) offer more benefits than non-immersive VR (screen-based, controller-driven rehab)?

In this post, I’ll dive into recent research on VR and TBI rehabilitation, break down how VR can enhance key aspects of recovery, and share clinical insights from my experience treating TBI patients with technology-driven interventions.

The Role of VR in a Comprehensive Rehab Plan

When working with TBI patients, rehabilitation must focus on motor function, cognition, and balance control simultaneously. A patient recovering from TBI isn’t just learning how to walk again; they’re also retraining executive function, visual processing, attention, and reaction times. This requires a structured, multisystem approach that incorporates movement facilitation and sensory stimulation in a way that is both progressive and engaging.

Traditional therapy methods often divide rehabilitation into separate disciplines—physical therapists (PTs) focus on movement and gait retraining, occupational therapists (OTs) work on activities of daily living and fine motor skills, and speech-language pathologists (SLPs) address cognitive-linguistic function. However, the challenge lies in bridging these areas to ensure patients are functionally integrating these skills in real-time, real-world scenarios. This is where virtual reality (VR) can make a difference, providing a safe, controlled environment that simulates real-life challenges, promotes active engagement, and enhances neuroplasticity through repetition and multisensory input.

A systematic review by Bonanno et al. (2022) found that immersive VR enhanced spatial awareness and executive function in TBI patients, suggesting a stronger engagement effect compared to non-immersive VR. However, while immersive VR can provide a more intense and realistic experience, it may not always be necessary for all aspects of rehab. In some cases, non-immersive VR still provides significant benefits, especially for balance and ADL training (Bonanno et al., 2022).

From my clinical experience, I’ve found that immersive VR tends to work better for patients further along in recovery, whereas non-immersive VR is more effective earlier in the process, particularly for postural control, early cognitive training, and structured balance activities. The key is knowing when—and how—to integrate these tools.

Immersive vs. Non-Immersive VR: A Progression Toward Greater Engagement and Recovery

The discussion around immersive versus non-immersive VR in TBI rehabilitation often centers on which approach is superior, but the reality is that both have an important role to play—especially when used in a progressive, patient-centered manner. Immersive VR (headsets, interactive 3D environments) creates a fully engaging, multisensory experience, while non-immersive VR (screen-based, controller-driven therapy) offers a more controlled and accessible entry point into virtual rehabilitation.

Research supports the benefits of immersive VR, with Aida et al. (2018) finding that 10 out of 11 studies demonstrated positive outcomes in motor function and cognitive engagement for TBI patients (Aida et al., 2018). The ability to fully immerse patients in a dynamic, interactive world enhances engagement and provides a more naturalistic approach to motor and cognitive training. The controlled yet stimulating environment of immersive VR may drive neuroplasticity through increased intensity and repetitions, reinforcing motor learning, spatial awareness, and cognitive recovery in ways traditional therapy cannot replicate.

However, not all patients are ready for full immersion right away. From a clinical standpoint, I’ve seen that patients with vestibular dysfunction, cognitive disorientation, or post-TBI fatigue may initially struggle with immersive VR, experiencing motion sickness, dizziness, or sensory overload. This is where non-immersive VR serves as a valuable stepping stone—allowing patients to gradually build tolerance, improve their visual and cognitive processing, and adjust to the demands of virtual environments before progressing to full immersion.

Rather than viewing non-immersive and immersive VR as competing methods, they should be seen as a progression toward higher-intensity rehabilitation. Calabrò et al. (2023) conducted a randomized controlled trial comparing non-immersive VR to traditional therapy for severe acquired brain injury and found that patients in the VR group demonstrated significantly greater cognitive and motor improvements (Calabrò et al., 2023). While non-immersive VR alone can enhance outcomes, its real strength may be in preparing patients for immersive VR, ultimately allowing them to handle higher doses of therapy with increased engagement, intensity, and repetitions.

From a real-world PT perspective, I see non-immersive VR as a gateway to immersive VR, allowing patients to gradually adapt before moving into a fully immersive, high-intensity environment. Immersive VR offers a superior opportunity for real-world task simulation, sensorimotor integration, and cognitive engagement, but its success hinges on proper patient selection, structured dosing, and gradual exposure. When used strategically, non-immersive VR can pave the way for immersive VR, leading to greater intensity, higher repetitions, and ultimately better functional outcomes.

How VR Enhances Key Components of TBI Rehabilitation

Motor Recovery

One of the biggest advantages of VR is the ability to increase repetition and intensity of movement training. Research has consistently shown that high-repetition movement training is critical for neuroplasticity.

A meta-analysis by Yang et al. (2019) found that VR-based rehab significantly improved motor function in TBI patients, with measurable gains in upper limb coordination, postural control, and mobility (Yang et al., 2019). The ability to engage patients in interactive, task-specific movement training makes VR an excellent adjunct to traditional therapy.

Balance and Sensory Integration

Balance dysfunction is one of the most persistent issues in TBI rehab, often leading to falls and decreased independence. Hernan et al. (2024) reviewed VR-based balance interventions and found that VR enhances sensorimotor training by incorporating visual, auditory, and vestibular feedback (Hernan et al., 2024).

I’ve personally seen VR-based balance training help TBI patients retrain their postural control and reactive stepping strategies, particularly when integrated with dynamic weight-shifting tasks, gaze stabilization, and real-time feedback.

Cognitive Engagement and Executive Function

TBI-related cognitive impairments can seriously impact functional independence. One of the most promising applications of VR is in cognitive rehab, particularly for attention, problem-solving, and memory training.

Shen et al. (2018) found that immersive VR was particularly beneficial in pediatric TBI patients, improving reaction time, attention, and executive function (Shen et al., 2018). Similarly, Grewal et al. (2024) highlighted VR’s ability to integrate cognitive training into functional ADL scenarios, providing a more ecologically valid rehab experience (Grewal et al., 2024).

Final Thoughts: A PT’s Perspective on VR in TBI Rehab

As we highlight TBI Awareness Month, it’s exciting to see research-backed technological advances in neurorehabilitation. VR is a powerful adjunct to traditional therapy—but it’s not a one-size-fits-all solution. The key is knowing when to use immersive vs. non-immersive VR, how to dose therapy intensity, and how to adapt VR interventions to each patient’s specific needs.

At the end of the day, VR isn’t replacing rehab—it’s enhancing it. And as a neuro rehab PT, I see that as an exciting step forward for TBI rehabilitation.

References:

Aida, J., Chau, B., & Dunn, J. (2018). Immersive virtual reality in traumatic brain injury rehabilitation: A literature review. NeuroRehabilitation, 42, 441-448.

Bonanno, M., De Luca, R., De Nunzio, A. M., Quartarone, A., & Calabrò, R. S. (2022). Innovative technologies in the neurorehabilitation of traumatic brain injury: A systematic review. Brain Sciences, 12(12), 1678.

Calabrò, R. S., Bonanno, M., & Torregrossa, W. (2023). Benefits of telerehabilitation for patients with severe acquired brain injury: A multicenter randomized controlled trial using non-immersive virtual reality. Journal of Medical Internet Research, 25, e45458.

Grewal, J., Eng, J. J., & Sakakibara, B. M. (2024). The use of virtual reality for activities of daily living rehabilitation after brain injury: A scoping review. Australian Occupational Therapy Journal, 71, 868-893.