Virtual Reality-Based Training to Improve Obstacle-Crossing Performance and Dynamic Balance in Patients With Parkinson's Disease

Virtual Reality Training Helpful in Motor and Cognition in Corticobasal Syndrome: A Case Report PET Study

Corticobasal syndrome (CBS) is a rare progressive neurodegenerative disease characterized by a combination of asymmetric motor symptoms and non-motor symptoms. CBS is poorly responsive to levodopa. Non-pharmacological strategies have been found to be useful as components of a multidisciplinary therapeutic approach for patients with CBS. The purpose of this study was to investigate the effects of virtual reality training in addressing symptoms of CBS. A 64-year-old man was clinically diagnosed as CBS one year after the onset of complaints. Positron emission tomography (PET) scan showed asymmetrical hypometabolism in the right thalamus and basal ganglia. The patient was evaluated for balance, gait, mobility, and cognition 1 week before, 1 week after, and 1 year after 6 weeks of training, 3 times weekly (18 sessions in total). All clinical outcomes and PET result had improved after the intervention; cognition and balance were maintained after 1 year. Additionally, the asymmetric hypometabolism, which had been detectable on the PET scan, became normal, and a relative improvement was noted in the visual evaluation of cortical involvement. Virtual reality may address different aspects of motor and cognition and possibly brain metabolic changes that can affect the course of the disease in patients with CBS.

An Immersive Virtual Reality Exergame for People with Parkinson’s Disease

Parkinson’s disease is a neurodegenerative disorder that affects primarily motor system. Physical exercise is considered important for people with Parkinson’s disease (PD) to slow down disease progression and maintain abilities and quality of life. However, people with PD often experience barriers to exercises that causes low-level adherence to exercise plans and programs. Virtual Reality (VR) is an innovative and promising technology for motor and cognitive rehabilitation. Immersive VR exergames have potential advantages by allowing for individualized skill practice in a motivating interactive environment without distractions from outside events. This paper presents an immersive virtual reality (VR) exergame aiming at motor training on fingers and hand-and-eye coordination. The results from the usability study indicate that immersive VR exergames have potential to provide motivating and engaging physical exercise for people with PD. Through this research, we hope to contribute to evidence-based design principles for task-specific immersive VR exergames for patients with Parkinson’s Disease.

Effectiveness of Physical Therapy Interventions in Reducing Fear of Falling Among Individuals With Neurologic Diseases: A Systematic Review and Meta-analysis

OBJECTIVE

To summarize the effectiveness of physical therapy interventions to reduce fear of falling (FOF) among individuals living with neurologic diseases.

DATA SOURCES

PubMed, Physiotherapy Evidence Database, Scopus, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, and SportDiscuss were searched from inception until December 2019.

STUDY SELECTION

Clinical trials with either the primary or secondary aim to reduce FOF among adults with neurologic diseases were selected.

DATA EXTRACTION

Potential articles were screened for eligibility, and data were extracted by 2 independent researchers. Risk of bias was assessed by the Cochrane Risk of Bias tool for randomized controlled trials and the National Institutes of Health Quality Assessment Tool for pre-post studies. A meta-analysis was performed among trials presenting with similar clinical characteristics. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to rate the overall quality of evidence.

RESULTS

Sixty-one trials with 3954 participants were included in the review and 53 trials with 3524 participants in the meta-analysis. The included studies presented, in general, with a low to high risk of bias. A combination of gait and balance training was significantly more effective compared with gait training alone in reducing FOF among individuals with Parkinson disease (PD) (mean difference [MD]=11.80; 95% CI, 8.22-15.38; P<.001). Home-based exercise and leisure exercise demonstrated significant improvement in reducing FOF over usual care in multiple sclerosis (MS) (MD=15.27; 95% CI, 6.15-24.38; P=.001). No statistically significant between-groups differences were reported among individuals with stroke and spinal cord injury. The overall quality of evidence presented in this review ranges from very low to moderate according to the assessment with the GRADE approach.

CONCLUSIONS

Gait with lower limb training combined with balance training is effective in reducing FOF in individuals with PD. Also, home-based or leisure exercise is effective among individuals with MS. However, because of several limitations of the included studies, further research is needed to examine the effectiveness of FOF intervention among individuals with neurologic diseases.

Effects of interactive video-game-based exercise on balance in older adults with mild-to-moderate Parkinson's disease

BACKGROUND

This study aimed to evaluate the effectiveness of a customized interactive video game-based (IVGB) training on balance in older adults with mild-to-moderate Parkinson's disease (PD).

METHODS

In this 12-week crossover trial, PD patients ≥65 years of age were randomly divided into Group A (a 6-week intervention phase followed by a 6-week control phase) and Group B (a 6-week control phase followed by a 6-week intervention phase). Participants received IVGB exercise training during the intervention phase and no exercise during the control phase. Functional outcomes were measured using behavioral evaluation scales and questionnaires at baseline, week 6 and week 12.

RESULTS

Twenty-four PD patients were included in this study, and were evenly divided into two groups. After Bonferroni adjustment, the changes in Modified Falls Efficacy Scale (MFES) and two subscales of Multi-Directional Reach Test were significantly different between two groups in the first 6-week period. In addition, the changes in Berg Balance Scale, MFES, and two subscales of Maximum Step Length were significantly different between two groups in the second 6-week period. Compared to controls, 6-week IVGB exercise intervention significantly improved different but overlapping functional outcomes in two groups of PD patients.

CONCLUSIONS

The customized IVGB exercise training improves balance, postural stability and confidence in preventing falls in older adults with mild-to-moderate PD. However, this IVGB exercise doesn't have a significant impact on quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT03689764 . Registered 27 September 2018, retrospectively registered.

Effect of Virtual Reality on Balance in Individuals With Parkinson Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Virtual reality (VR) is a frequently used intervention for the rehabilitation of individuals with neurological disorders.

PURPOSE

The aims of this review were to identify the short-term effect of VR on balance and to compare it with the effect of active interventions in individuals with Parkinson disease (PD).

DATA SOURCES

Searches for relevant articles available in English were conducted using the MEDLINE (via PubMed), EMBASE, CENTRAL, CINAHL, PsycINFO, and Physiotherapy Evidence Database databases from inception until March 2019.

STUDY SELECTION

All randomized controlled trials comparing the effect of training with VR and the effect of training without VR on balance in individuals with PD were included.

DATA EXTRACTION

Two authors independently extracted data, assessed the methodological quality, and evaluated the evidence quality of the studies.

DATA SYNTHESIS

Fourteen randomized controlled trials including 574 individuals were eligible for qualitative analyses, and 12 of the studies involving 481 individuals were identified as being eligible for meta-analyses. Compared with active interventions, the use of VR improved the Berg Balance Scale score (mean difference = 1.23; 95% CI = 0.15 to 2.31; I2 = 56%). The Dynamic Gait Index and Functional Gait Assessment results were also significant after the sensitivity analyses (mean difference = 0.69; 95% CI = 0.12 to 1.26; I2 = 0%). Both provided moderate statistical evidence. However, the Timed "Up & Go" Test and the Activities-Specific Balance Confidence Scale did not differ significantly.

LIMITATIONS

Publication bias and diversity in the interventions were the main limitations.

CONCLUSIONS

Existing moderate evidence of the effectiveness of VR with the Berg Balance Scale, Dynamic Gait Index, and Functional Gait Assessment for individuals with PD was promising. Although the differences did not reach the clinically important change threshold, VR was comparable to active interventions and could be considered an adjuvant therapy for balance rehabilitation in individuals with PD.

Exergames for balance dysfunction in neurological disability: a meta-analysis with meta-regression

OBJECTIVE

To evaluate systematically the efficacy of exergames for balance dysfunction in neurological conditions and to identify factors of exergaming protocols that may influence their effects.

METHODS

We searched electronic databases for randomized clinical trials investigating the effect of commercial exergames versus alternative interventions on balance dysfunction as assessed by standard clinical scales in adults with acquired neurological disabilities. Standardized mean differences (Hedge's g) were calculated with random-effects models. Subgroup analyses and meta-regression were run to explore potential modifiers of effect size.

RESULTS

Out of 106 screened articles, 41 fulfilled criteria for meta-analysis, with a total of 1223 patients included. Diseases under investigation were stroke, Parkinson's disease, multiple sclerosis, mild cognitive impairment or early Alzheimer's disease, traumatic brain injury, and myelopathy. The pooled effect size of exergames on balance was moderate (g = 0.43, p < 0.001), with higher frequency (number of sessions per week) associated with larger effect (β = 0.24, p = 0.01). There was no effect mediated by the overall duration of the intervention and intensity of a single session. The beneficial effect of exergames could be maintained for at least 4 weeks after discontinuation, but their retention effect was specifically explored in only 11 studies, thus requiring future investigation. Mild to moderate adverse events were reported in a minority of studies. We estimated a low risk of bias, mainly attributable to the lack of double-blindness and not reporting intention-to-treat analysis.

CONCLUSIONS

The pooled evidence suggests that exergames improve balance dysfunction and are safe in several neurological conditions. The findings of high-frequency interventions associated with larger effect size, together with a possible sustained effect of exergaming, may guide treatment decisions and inform future research.

Postural control learning dynamics in Parkinson's disease: early improvement with plateau in stability, and continuous progression in flexibility and mobility

BACKGROUND

Balance training improves postural control in Parkinson's disease (PD). However, a systematic approach for the development of individualized, optimal training programs is still lacking, as the learning dynamics of the postural control in PD, over a training program, are poorly understood.

OBJECTIVES

We investigated the learning dynamics of the postural control in PD, during a balance-training program, in terms of the clinical, posturographic, and novel model-based measures.

METHODS

Twenty patients with PD participated in a balance-training program, 3 days a week, for 6 weeks. Clinical tests assessed functional balance and mobility pre-training, mid-training, and post-training. Center-of-pressure (COP) was recorded at four time-points during the training (pre-, week 2, week 4, and post-training). COP was used to calculate the sway measures and to identify the parameters of a patient-specific postural control model, at each time-point. The posturographic and model-based measures constituted the two sets of stability- and flexibility-related measures.

RESULTS

Mobility- and flexibility-related measures showed a continuous improvement during the balance-training program. In particular, mobility improved at mid-training and continued to improve to the end of the training, whereas flexibility-related measures reached significance only at the end. The progression in the balance- and stability-related measures was characterized by early improvements over the first 3 to 4 weeks of training, and reached a plateau for the rest of the training.

CONCLUSIONS

The progression in balance and postural stability is achieved earlier and susceptible to plateau out, while mobility and flexibility continue to improve during the balance training.

Additional Physical Interventions to Conventional Physical Therapy in Parkinson's Disease: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Parkinson’s disease (PD) represents the second most common neurodegenerative disease. Currently, conventional physical therapy is complemented by additional physical interventions with recreational components, improving different motor conditions in people with PD. This review aims to evaluate the effectiveness of additional physical interventions to conventional physical therapy in Parkinson’s disease. A systematic review and meta-analysis of randomized controlled trials were performed. The literature search was conducted in PubMed, Physiotherapy Evidence Database (PEDro), Scopus, SciELO and Web of Science. The PEDro scale was used to evaluate the methodological quality of the studies. A total of 11 randomized controlled trials were included in this review. Five of them contributed information to the meta-analysis. The statistical analysis showed favorable results for dance-based therapy in motor balance: (Timed Up and Go: standardized mean difference (SMD) = −1.16; 95% Confidence Interval (CI):(−2.30 to −0.03); Berg Balance Scale: SMD = 4.05; 95%CI:(1.34 to 6.75)). Aquatic interventions showed favorable results in balance confidence (Activities-Specific Balance Confidence: SMD=10.10; 95%CI:(2.27 to 17.93)). The results obtained in this review highlight the potential benefit of dance-based therapy in functional balance for people with Parkinson’s disease, recommending its incorporation in clinical practice. Nonetheless, many aspects require clarification through further research and high-quality studies on this subject.

Efficacy of the Nintendo Wii combination with Conventional Exercises in the rehabilitation of individuals with Parkinson's disease: A randomized clinical trial

BACKGROUND

Studies have demonstrated that the combination of Nintendo Wii (NW) with Conventional Exercises (CE) was effective in the rehabilitation of patients with Parkinson's Disease (PD), but there are no studies comparing the effects of this combination on both techniques isolated.

OBJECTIVE

To investigate if the effects of the combination of NW to CE are superior to isolated techniques in the rehabilitation of balance, gait, functional mobility and improvement of the quality of life of individuals with PD.

METHODS

45 patients with PD were divided into three groups, NW alone, CE alone and NW plus EC. The sessions occurred for 50 minutes, twice a week and evaluations administered before and after the 2-month intervention.

RESULTS

Significant differences were found in the pre and post intervention analyzes of all the outcomes in the three groups, but there was no difference between the groups. The effect size was evaluated, in which the NW plus CE group had a greater magnitude of the therapeutic effect.

CONCLUSION

The NW plus CE was statistically as effective as each intervention alone in the rehabilitation of patients with PD, however, the use of this combination provided a magnitude of the therapeutic effect superior to the other groups.

Cueing Paradigms to Improve Gait and Posture in Parkinson's Disease: A Narrative Review

Progressive gait dysfunction is one of the primary motor symptoms in people with Parkinson’s disease (PD). It is generally expressed as reduced step length and gait speed and as increased variability in step time and step length. People with PD also exhibit stooped posture which disrupts gait and impedes social interaction. The gait and posture impairments are usually resistant to the pharmacological treatment, worsen as the disease progresses, increase the likelihood of falls, and result in higher rates of hospitalization and mortality. These impairments may be caused by perceptual deficiencies (poor spatial awareness and loss of temporal rhythmicity) due to the disruptions in processing intrinsic information related to movement initiation and execution which can result in misperceptions of the actual effort required to perform a desired movement and maintain a stable posture. Consequently, people with PD often depend on external cues during execution of motor tasks. Numerous studies involving open-loop cues have shown improvements in gait and freezing of gait (FoG) in people with PD. However, the benefits of cueing may be limited, since cues are provided in a consistent/rhythmic manner irrespective of how well a person follows them. This limitation can be addressed by providing feedback in real-time to the user about performance (closed-loop cueing) which may help to improve movement patterns. Some studies that used closed-loop cueing observed improvements in gait and posture in PD, but the treadmill-based setup in a laboratory would not be accessible outside of a research setting, and the skills learned may not readily and completely transfer to overground locomotion in the community. Technologies suitable for cueing outside of laboratory environments could facilitate movement practice during daily activities at home or in the community and could strongly reinforce movement patterns and improve clinical outcomes. This narrative review presents an overview of cueing paradigms that have been utilized to improve gait and posture in people with PD and recommends development of closed-loop wearable systems that can be used at home or in the community to improve gait and posture in PD.

The role of virtual reality on outcomes in rehabilitation of Parkinson's disease: meta-analysis and systematic review in 1031 participants

Introduction

Parkinson’s disease (PD) is managed primarily by dopamine agonists and physiotherapy while virtual reality (VR) has emerged recently as a complementary method. The present study reviewed the effectiveness of VR in rehabilitation of patients with PD.

Methods

Literature search up to June 2019 identified ten studies (n = 343 participants) suitable for meta-analysis and 27 studies (n = 688 participants) for systematic review. Standard mean difference (SMD) and 95% confidence intervals (CI) were calculated using a random effects model.

Results

In meta-analysis, compared with active rehabilitation intervention, VR training led to greater improvement of stride length, SMD = 0.70 (95%CI = 0.32–1.08, p = 0.0003), and was as effective for gait speed, balance and co-ordination, cognitive function and mental health, quality of life and activities of daily living. Compared with passive rehabilitation intervention, VR had greater effects on balance: SMD = 1.02 (95%CI = 0.38–1.65, p = 0.002). Results from single randomised controlled trials showed that VR training was better than passive rehabilitation intervention for improving gait speed SMD = 1.43 (95%CI = 0.51–2.34, p = 0.002), stride length SMD = 1.27 (95%CI = 0.38–2.16, p = 0.005) and activities of daily living SMD = 0.96 (95%CI = 0.02–1.89). Systematic review showed that VR training significantly (p < 0.05) improved motor function, balance and co-ordination, cognitive function and mental health, and quality of life and activities of daily living.

Conclusion

VR used in rehabilitation for patients with PD improves a number of outcomes and may be considered for routine use in rehabilitation.

Electronic supplementary material

The online version of this article (10.1007/s10072-019-04144-3) contains supplementary material, which is available to authorized users.

Virtual reality exposure therapy for neuro-psychomotor recovery in adults: a systematic review

OBJECTIVE

To analyse the virtual reality applications in the subjects' neuro-psychomotor functions rehabilitation with motor and/or neuropsychiatric impairment.

METHODS

The search was carried out in nine databases (Scopus, PubMed, Web of Science, ScienceDirect, Cochrane Library, CINAHL, PsycINFO, LILACS, and SciELO), from December 2017 to March 2019. An additional manual search was performed, taking into consideration references of the included papers, through the same eligibility criteria. The methodological quality of the included papers was evaluated using the Physiotherapy Evidence Database (PEDro).

RESULTS

One hundred and twenty-two papers were selected by the initial screening, but only 33 studies participated in the final inclusion in the study (11 clinical trials and 14 experimental studies). The data extracted were: the proposed objective, the sample population, the neurological condition treated, the VR modality used in the procedures and the study intervention period.

CONCLUSIONS

Virtual reality supports the rehabilitation process of neuro-psychomotor functions, allowing potential gains in the patients' recovery. Therefore, its development facilitates its availability and access in the future.Implications for rehabilitationIt has minimal adverse effects during the virtual therapies performance, such as the presence of vertigo related to cybersickness conditions, suggesting virtual reality as a safe rehabilitation tool, compared to other therapies.Virtual reality use is useful and effective in helping the rehabilitation process of motor, cognitive and psychosocial functions.It plays a role as an adjunctive and complementary therapy in the neuro-psychomotor rehabilitation process to obtain a clinically significant result.

Virtual-Reality-Induced Visual Perturbations Impact Postural Control System Behavior

Background: Virtual reality (VR) is becoming a widespread tool in rehabilitation, especially for postural stability. However, the impact of using VR in a “moving wall paradigm” (visual perturbation), specifically without and with anticipation of the perturbation, is unknown. Methods: Nineteen healthy subjects performed three trials of static balance testing on a force plate under three different conditions: baseline (no perturbation), unexpected VR perturbation, and expected VR perturbation. The statistical analysis consisted of a 1 × 3 repeated-measures ANOVA to test for differences in the center of pressure (COP) displacement, 95% ellipsoid area, and COP sway velocity. Results: The expected perturbation rendered significantly lower (p < 0.05) COP displacements and 95% ellipsoid area compared to the unexpected condition. A significantly higher (p < 0.05) sway velocity was also observed in the expected condition compared to the unexpected condition. Conclusions: Postural stability was lowered during unexpected visual perturbations compared to both during baseline and during expected visual perturbations, suggesting that conflicting visual feedback induced postural instability due to compensatory postural responses. However, during expected visual perturbations, significantly lowered postural sway displacement and area were achieved by increasing the sway velocity, suggesting the occurrence of postural behavior due to anticipatory postural responses. Finally, the study also concluded that VR could be used to induce different postural responses by providing visual perturbations to the postural control system, which can subsequently be used as an effective and low-cost tool for postural stability training and rehabilitation.

Effects of virtual reality rehabilitation training on gait and balance in patients with Parkinson's disease: A systematic review

OBJECTIVE

In recent years, virtual reality (VR) has been tested as a therapeutic tool in neurorehabilitation research. However, the impact effectiveness of VR technology on for Parkinson's Disease (PD) patients is still remains controversial unclear. In order to provide a more scientific basis for rehabilitation of PD patients' modality, we conducted a systematic review of VR rehabilitation training for PD patients and focused on the improvement of gait and balance.

METHODS

An comprehensive search was conducted using the following databases: PubMed, Web of Science, Cochrane Library, CINHAL, Embase and CNKI (China National Knowledge Infrastructure).Articles published before 30 December 2018 and of a randomized controlled trial design to study the effects of VR for patients with PD were included. The study data were pooled and a meta-analysis was completed. This systematic review was conducted in accordance with the PRISMA guideline statement and was registered in the PROSPERO database (CRD42018110264).

RESULTS

A total of sixteen articles involving 555 participants with PD were included in our analysis. VR rehabilitation training performed better than conventional or traditional rehabilitation training in three aspects: step and stride length (SMD = 0.72, 95%CI = 0.40,1.04, Z = 4.38, P<0.01), balance function (SMD = 0.22, 95%CI = 0.01,0.42, Z = 2.09, P = 0.037), and mobility(MD = -1.95, 95%CI = -2.81,-1.08, Z = 4.41, P<0.01). There was no effect on the dynamic gait index (SMD = -0.15, 95%CI = -0.50,0.19, Z = 0.86, P = 0.387), and gait speed (SMD = 0.19, 95%CI = -0.03,0.40, Z = 1.71, P = 0.088).As for the secondary outcomes, compared with the control group, VR rehabilitation training demonstrated more significant effects on the improvement of quality of life (SMD = -0.47, 95%CI = -0.73,-0.22, Z = 3.64, P<0.01), level of confidence (SMD = -0.73, 95%CI = -1.43,-0.03, Z = 2.05, P = 0.040), and neuropsychiatric symptoms (SMD = -0.96, 95%CI = -1.27,-0.65, Z = 6.07, P<0.01), while it may have similar effects on global motor function (SMD = -0.50, 95%CI = -1.48,0.48, Z = 0.99, P = 0.32), activities of daily living (SMD = 0.25, 95%CI = -0.14,0.64, Z = 1.24, P = 0.216), and cognitive function (SMD = 0.21, 95%CI = -0.28,0.69, Z = 0.84, P = 0.399).During the included interventions, four patients developed mild dizziness and one patient developed severe dizziness and vomiting.

CONCLUSIONS

According to the results of this study, we found that VR rehabilitation training can not only achieve the same effect as conventional rehabilitation training. Moreover, it has better performance on gait and balance in patients with PD. Taken together, when the effect of traditional rehabilitation training on gait and balance of PD patients is not good enough, we believe that VR rehabilitation training can at least be used as an alternative therapy. More rigorous design of large-sample, multicenter randomized controlled trials are needed to provide a stronger evidence-based basis for verifying its potential advantages.

Effects of the Nintendo Wii training on balance rehabilitation and quality of life of patients with Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

Randomized clinical trials (RCTs) used the Nintendo Wii (NW) in the treatment of Parkinson Disease, however, no meta-analysis was developed to determine the effects in these patients.

OBJECTIVE

To analyze RCTs that investigated the effects of NW versus traditional physiotherapy on balance rehabilitation and quality of life of patients with PD.

METHODS

Electronic research was conducted between December 2018 and January 2019 in the MEDLINE, PEDro, CENTRAL, LILACS and SciELO databases. The methodological quality was evaluated by the PEDro scale and the completeness of the description of the interventions by the TIDieR checklist. Weighted mean differences (WMD) and 95% confidence interval (CI) were calculated.

RESULTS

Five studies were included and presented an average of 5.4 (1.5) on the PEDro scale and 6.7 (1.4) on the TIDieR. Compared to traditional physiotherapy, combined NW and traditional physiotherapy resulted in improvement in balance WMD 1.24 (95% CI: CI: 0.2 to 2.3 N = 72) and quality of life WMD- 8.9 (95% CI: -15.2 to -2.6 N = 56).

CONCLUSION

combined NW and traditional physiotherapy was more effective on balance rehabilitation and quality of life of patients with PD, but the values demonstrated a poor methodological quality and a low level of completeness of the intervention descriptions.

Advantages of using 3D virtual reality based training in persons with Parkinson's disease: a parallel study

BACKGROUND

Parkinson's disease (PD) is a slowly progressive neurodegenerative disease. There are mixed reports on success of physiotherapy in patients with PD. Our objective was to investigate the functional improvements, motivation aspects and clinical effectiveness when using immersive 3D virtual reality versus non-immersive 2D exergaming.

METHODS

We designed a randomized parallel study with 97 patients, but only 20 eligible participants were randomized in 2 groups; the one using 3D Oculus Rift CV1 and the other using a laptop. Both groups participated in the 10-session 3 weeks training with a pick and place task in the virtual world requiring precise hand movement to manipulate the virtual cubes. The kinematics of the hand was traced with Leap motion controller, motivation effect was assessed with modified Intrinsic Motivation Inventory and clinical effectiveness was evaluated with Box & Blocks Test (BBT) and shortened Unified Parkinson's disease rating scale (UPDRS) before and after the training. Mack-Skilling non-parametrical statistical test was used to identify statistically significant differences (p < 0.05) and Cohen's U3 test to find the effect sizes.

RESULTS

Participants in the 3D group demonstrated statistically significant and substantially better performance in average time of manipulation (group x time, p = 0.009), number of successfully placed cubes (group x time, p = 0.028), average tremor (group x time, p = 0.002) and UPDRS for upper limb (U3 = 0.35). The LCD and 3D groups substantially improved their BBT score with training (U3 = 0.7, U3 = 0.6, respectively). However, there were no statistically significant differences in clinical tests between the groups (group x time, p = 0.2189, p = 0.2850, respectively). In addition the LCD group significantly decreased the pressure/tension (U3 = 0.3), the 3D did not show changes (U3 = 0.5) and the differences between the groups were statistically different (p = 0.037). The 3D group demonstrated important increase in effort (U3 = 0.75) and perceived competences (U3 = 0.9).

CONCLUSIONS

The outcomes of the study demonstrated that the immersive 3D technology may bring increased interests/enjoyment score resulting in faster and more efficient functional performance. But the 2D technology demonstrated lower pressure/tension score providing similar clinical progress. A study with much larger sample size may also confirm the clinical effectiveness of the approaches.

TRIAL REGISTRATION

The small scale randomized pilot study has been registered at ClinicalTrials.gov Identifier: NCT03515746 , 4 May 2018.

Is virtual reality beneficial for dual-task gait training in patients with Parkinson's disease? A systematic review

This systematic review examined the evidence about the effects of virtual reality (VR) on dual-task gait training in Parkinson's disease (PD).

Treatment options for postural instability and gait difficulties in Parkinson's disease

Introduction: Gait and balance disorders in Parkinson's disease (PD) represent a major therapeutic challenge as frequent falls and freezing of gait impair quality of life and predict mortality. Limited dopaminergic therapy responses implicate non-dopaminergic mechanisms calling for alternative therapies.Areas covered: The authors provide a review that encompasses pathophysiological changes involved in axial motor impairments in PD, pharmacological approaches, exercise, and physical therapy, improving physical activity levels, invasive and non-invasive neurostimulation, cueing interventions and wearable technology, and cognitive interventions.Expert opinion: There are many promising therapies available that, to a variable degree, affect gait and balance disorders in PD. However, not one therapy is the 'silver bullet' that provides full relief and ultimately meaningfully improves the patient's quality of life. Sedentariness, apathy, and emergence of frailty in advancing PD, especially in the setting of medical comorbidities, are perhaps the biggest threats to experience sustained benefits with any of the available therapeutic options and therefore need to be aggressively treated as early as possible. Multimodal or combination therapies may provide complementary benefits to manage axial motor features in PD, but selection of treatment modalities should be tailored to the individual patient's needs.

Exercise for Parkinson's disease

Parkinson's disease is the second most common neurodegenerative disease with a prevalence rate of 1-2 per 1000 of the population worldwide. Pharmacological management is the mainstay of treatment. Despite optimal medication, motor impairment particularly balance and gait impairment persist leading to various degree of disability and reduced quality-of-life. The present review describes motor impairment including postural impairment, gait dysfunction, reduced muscle strength and aerobic capacity and falls. Physical therapy and complementary exercises have been proven to improve motor performance and functional mobility. Evidence on the efficacy of physical therapy and complementary exercises is presented in this review. These exercises include gait training with cues, gait training with treadmill, Nordic walking, brisk walking, balance training, virtual reality interventions, Tai Chi and dance. All these treatment interventions produce short-term beneficial effects and some interventions demonstrate long-term benefit. Gait training with treadmill enhance walking performance and the effects sustain for 3-6 months. Balance training improves balance, function and reduces fall rate, and these effects carry over to at least 12 months after training ended. Sustained Tai Chi for 6 months, dance therapy for 12 months, progressive resistive training for 24 months alleviates the PD motor symptoms, suggesting that they could slow down PD progression. Based on this evidence, individuals with PD are encouraged to sustain their training in order to improve/maintain their physical ability and to combat the progression of PD.

The State of Behavior Change Techniques in Virtual Reality Rehabilitation of Neurologic Populations

Background: Neurologic rehabilitation aims to restore function, address barriers to activity, and improve quality of life in those with injury to the nervous system. Virtual reality (VR) has emerged as a useful tool to enhance neurorehabilitation interventions and outcomes. However, the manner in which VR-based neurorehabilitation has been manipulated to optimize outcomes using theory-based frameworks has not been documented. Behavior Change Techniques (BCTs) are described as the smallest active ingredient in an intervention aimed to change behavior via theoretically-proposed pathways. The purpose of this review was to investigate the ways VR is being used in neurorehabilitation to improve upright mobility, and systematically code those VR interventions for active BCTs.

Methods: Keyword searches were performed using database searches of PubMed, SPORTDiscus, and psycINFO. The search yielded 32 studies for inclusion. Coding for BCTs was conducted using the Behavior Change Techniques Taxonomy v1 (BCTTv1).

Results: Behavioral Practice, Graded Tasks, Biofeedback, and Explicit Feedback were the most commonly used BCTs. All studies reported improvements in motor performance outcomes. However, none of the studies investigated the efficacy of each component of their VR intervention making it difficult to point to the most effective components of VR interventions overall.

Conclusions: This review suggests that investigation into the specific components of VR interventions, along with purposeful implementation and reporting of BCTs will help improve understanding of the efficacy of VR as a neurorehabilitation tool. Future research could benefit from incorporating BCTs into the design process of VR interventions to produce optimal rehabilitation potential.

Effect of virtual reality on balance and gait ability in patients with Parkinson's disease: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to evaluate the effectiveness of virtual reality interventions for improving balance and gait in people with Parkinson's disease.

DESIGN

This is a systematic review and meta-analysis of randomized controlled trials.

METHODS

Databases of MEDLINE, Cochran Central Register of Controlled Trials, EMBASE, PEDro, Web of Science and China Biology Medicine disc were searched from their inception up to 1 March 2019. Two reviewers individually appraised literatures for inclusion, extracted data and evaluated trial quality.

RESULTS

A total of 12 studies with a median PEDro score of 6.4 and involving 419 participants were included. This review first demonstrated significant improvements in Berg Balance Scale (mean difference = 2.69; 95% confidence interval = 1.37 to 4.02; p < 0.0001), Timed Up and Go Test (mean difference = -2.86; 95% confidence interval = -5.60 to -0.12; p = 0.04) and stride length (mean difference = 9.65; 95% confidence interval = 4.31 to 14.98; p = 0.0004) in Parkinson patients who received virtual reality compared with controls. However, there was no significant difference in gait velocity and walk distance.

CONCLUSION

This systematic review and meta-analysis supports the use of virtual reality to enhance the balance of patients with Parkinson's disease. However, the review does not find any definite effect upon gait by the use of virtual reality.

Motor Learning Deficits in Parkinson's Disease (PD) and Their Effect on Training Response in Gait and Balance: A Narrative Review

Parkinson's disease (PD) is a neurological disorder traditionally associated with degeneration of the dopaminergic neurons within the substantia nigra, which results in bradykinesia, rigidity, tremor, and postural instability and gait disability (PIGD). The disorder has also been implicated in degradation of motor learning. While individuals with PD are able to learn, certain aspects of learning, especially automatic responses to feedback, are faulty, resulting in a reliance on feedforward systems of movement learning and control. Because of this, patients with PD may require more training to achieve and retain motor learning and may require additional sensory information or motor guidance in order to facilitate this learning. Furthermore, they may be unable to maintain these gains in environments and situations in which conscious effort is divided (such as dual-tasking). These shortcomings in motor learning could play a large part in degenerative gait and balance symptoms often seen in the disease, as patients are unable to adapt to gradual sensory and motor degradation. Research has shown that physical and exercise therapy can help patients with PD to adapt new feedforward strategies to partially counteract these symptoms. In particular, balance, treadmill, resistance, and repeated perturbation training therapies have been shown to improve motor patterns in PD. However, much research is still needed to determine which of these therapies best alleviates which symptoms of PIGD, the needed dose and intensity of these therapies, and long-term retention effects. The benefits of such technologies as augmented feedback, motorized perturbations, virtual reality, and weight-bearing assistance are also of interest. This narrative review will evaluate the effect of PD on motor learning and the effect of motor learning deficits on response to physical therapy and training programs, focusing specifically on features related to PIGD. Potential methods to strengthen therapeutic effects will be discussed.

Recent advances in rehabilitation for Parkinson's Disease with Exergames: A Systematic Review

OBJECTIVE

The goal of this contribution is to gather and to critically analyze recent evidence regarding the potential of exergaming for Parkinson's disease (PD) rehabilitation and to provide an up-to-date analysis of the current state of studies on exergame-based therapy in PD patients.

METHODS

We performed our search based on the conclusions of a previous systematic review published in 2014. Inclusion criteria were articles published in the indexed databases Pubmed, Scopus, Sciencedirect, IEEE and Cochrane published since January 1, 2014. Exclusion criteria were papers with a target group other than PD patients exclusively, or contributions not based on exergames. Sixty-four publications out of 525 matches were selected.

RESULTS

The analysis of the 64 selected publications confirmed the putative improvement in motor skills suggested by the results of the previous review. The reliability and safety of both Microsoft Kinect and Wii Balance Board in the proposed scenarios was further confirmed by several recent studies. Clinical trials present better (n = 5) or similar (n = 3) results than control groups (traditional rehabilitation or regular exercise) in motor (TUG, BBS) and cognitive (attention, alertness, working memory, executive function), thus emphasizing the potential of exergames in PD. Pilot studies (n = 11) stated the safety and feasibility of both Microsoft Kinect and Wii Balance Board, potentially in home scenarios as well. Technical papers (n = 30) stated the reliability of balance and gait data captured by both devices. Related meta-analyses and systematic reviews (n = 15) further support these statements, generally citing the need for adaptation to patient's skills and new input devices and sensors as identified gaps.

CONCLUSION

Recent evidence indicates exergame-based therapy has been widely proven to be feasible, safe, and at least as effective as traditional PD rehabilitation. Further insight into new sensors, best practices and different cognitive stadiums of PD (such as PD with Mild Cognitive Impairment), as well as task specificity, are required. Also, studies linking game parameters and results with traditional assessment methods, such as UPDRS scores, are required. Outcomes for randomized controlled trials (RCTs) should be standardized, and follow-up studies are required, particularly for motor outcomes.

Virtual and Augmented Reality Mirrors for Mental Health Treatment

Virtual and Augmented Reality are technologies widely used in a variety of areas, including the medical sector. On the other hand, regular mirrors have been traditionally used as tools to aid in mental health treatment for a variety of diseases and disorders. Although it is possible to build Virtual and Augmented Reality experiences based on mirror metaphors, there are very few contributions of this kind in the medical sector. In this chapter, the great benefits that regular mirrors have brought for mental health treatment are addressed. In addition, a review on the state of the art in mirror-based Virtual and Augmented Reality applications is given, highlighting the potential benefits that these enhanced mirrors could bring for the mental health treatment.

Comparing Balance Performance on Force Platform Measures in Individuals with Parkinson's Disease and Healthy Adults

INTRODUCTION

Postural instability is a known contributing factor to balance dysfunction and increased fall risk in those with Parkinson's disease (PD). Computerized posturography employing a force platform system provides objective, quantitative assessments of postural control impairments. This study examines balance performance as measured by force platform (FP) tests in persons with PD compared to age-matched healthy adults. Secondarily, we examine if these FP measures provide diagnostic and clinically meaningful information about the underlying balance impairments in the PD population.

METHODS

Participants-42 individuals with PD (Hoehn and Yahr stage = 2.33 ± 0.77) and 55 age-matched healthy adults-were assessed on three standardized balance measures on a computerized force platform system. Between groups, comparisons of FP performance were analyzed using independent t-test. Within the group, comparisons for the PD cohort were analyzed using ANOVA for comparing disease stage and Mann-Whitney U test for PD subtypes.

RESULTS

The PD cohort demonstrated significantly greater postural instability on the sensory organization test (SOT) measures (P=0.013, CI-95% = 1.286 to 10.37) and slower movement velocity on the limits of stability (LOS) test (P=0.001, CI-95% = 0.597 to 1.595) than the healthy cohort, suggesting that these tests were sensitive to detect sensory integration and voluntary postural control deficits in the PD cohort. Within the PD group, the SOT differentiated between H&Y stages 1-3. The motor control test (MCT) detected changes in reactive postural control mainly in later disease stages. All three FP tests distinguished between PD subtypes, with the Posture Gait Instability subtype demonstrating poorer balance performance than Tremor Dominant subtype.

CONCLUSION

These findings suggest FP measures provide clinically meaningful, diagnostic information in the examination of balance impairments in individuals with PD. FP measures may inform clinicians regarding intrinsic balance deficits and guide them in designing targeted balance interventions to reduce fall risk in persons with PD.

The Clinical Utility of Virtual Reality in Neurorehabilitation: A Systematic Review

Background:

Virtual reality (VR) experiences (through games and virtual environments) are increasingly being used in physical, cognitive, and psychological interventions. However, the impact of VR as an approach to rehabilitation is not fully understood, and its advantages over traditional rehabilitation techniques are yet to be established.

Method:

We present a systematic review which was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). During February and March of 2018, we conducted searches on PubMed (Medline), Virtual Health Library Search Portal databases (BVS), Web of Science (WOS), and Embase for all VR-related publications in the past 4 years (2015, 2016, 2017, and 2018). The keywords used in the search were “neurorehabilitation” AND “Virtual Reality” AND “devices.”

Results:

We summarize the literature which highlights that a range of effective VR approaches are available. Studies identified were conducted with poststroke patients, patients with cerebral palsy, spinal cord injuries, and other pathologies. Healthy populations have been used in the development and testing of VR approaches meant to be used in the future by people with neurological disorders. A range of benefits were associated with VR interventions, including improvement in motor functions, greater community participation, and improved psychological and cognitive function.

Conclusions:

The results from this review provide support for the use of VR as part of a neurorehabilitation program in maximizing recovery.

The effectiveness of virtual reality training in reducing the risk of falls among elderly people

Background

Virtual reality (VR) training using modern game consoles is an innovative rehabilitation method for fall-prone elderly people. The aim of this study was to assess the effectiveness of VR training using the "Xbox 360 Kinect" in people over 60 years of age.

Materials and methods

The study involved 23 people, including 19 women and 4 men (mean age 75.74±8.09 years). The following functional tests were employed as research instruments: the 6-minute walking test (6MWT), the Dynamic Gait Index (DGI), the tandem stance test (TST), the tandem walk test (TWT), and the Beck Depression Inventory (BDI). A "spring hand dynamometer" was also used. The participants underwent 30-day VR training using an Xbox 360 Kinect. They trained 3 times a week, with each exercise lasting 30 minutes.

Results

The 6MWT (P<0.001), the DGI (P=0.008), the TST (P<0.001), the TWT (P=0.002), and the BDI (P<0.001) outcomes were significantly improved. There were differences in the results for the strength of the "pressing muscles" in the right (P=0.106) and left (P=0.043) hands of the participants. Both participants under 80 years of age and those aged 80 years and over had visibly better results on the 6MWT (P<0.001 and P=0.008, respectively), the TST (P<0.001 and P=0.008, respectively), and the BDI (P=0.003 and P=0.012, respectively).

Conclusion

Training based on VR increases the possibilities of motor training and can help reduce the risk of falls by improving the static and dynamic balance.

Standards of Virtual Reality Application in Balance Training Programs in Clinical Practice: A Systematic Review

OBJECTIVE

To determine the effect of virtual reality (VR) games on improving balance in different groups of neurological patients with a particular focus on the study quality and to determine the gold standard in VR training in these groups.

MATERIALS AND METHODS

A systematic review of controlled trials published between January 2009 and December 2017 was conducted. The PubMed, SCOPUS, SPORTDiscus, and Medline databases were searched. Studies involved patients with stroke or Parkinson's disease or children with cerebral palsy. The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies.

RESULTS

A total of 20 studies met the inclusion criteria. The PEDro scores ranged from 4 to 8 points. Analysis of the rehabilitation programs revealed a very large discrepancy in the planned volume of exercises in different subgroups of patients.

CONCLUSIONS

Overall, the comparison of VR interventions between conventional rehabilitation and no intervention exhibited significantly better results. However, these results should be interpreted with great caution due to the large diversity of the systems, games, and training volume used in the VR therapy. In all included studies, only several articles included objective methods to assess the effect of VR. In addition, most of the articles showed a high risk of bias, such as a lack of randomization and blinding or a small sample size. That is why further well-designed randomized control trials are required to evaluate the influence of VR on balance in different groups of neurological patients.

Neurophilosophical and Ethical Aspects of Virtual Reality Therapy in Neurology and Psychiatry

Highly immersive virtual reality (VR) systems have been introduced into the consumer market in recent years. The improved technological capabilities of these systems as well as the combination with biometric sensors, for example electroencephalography (EEG), in a closed-loop hybrid VR-EEG, opens up a range of new potential medical applications. This article first provides an overview of the past and current clinical applications of VR systems in neurology and psychiatry and introduces core concepts in neurophilosophy and VR research (such as agency, trust, presence, and others). Then, important adverse effects of highly immersive VR simulations and the ethical implications of standalone and hybrid VR systems for therapy in neurology and psychiatry are highlighted. These new forms of VR-based therapy may strengthen patients in exercising their autonomy. At the same time, however, these emerging systems present ethical challenges, for example in terms of moral and legal accountability in interactions involving “intelligent” hybrid VR systems. A user-centered approach that is informed by the target patients’ needs and capabilities could help to build beneficial systems for VR therapy.

Motivators and Barriers to Exercise in Parkinson's Disease

BACKGROUND

Despite evidence for the benefits of exercise in Parkinson's disease (PD), many patients remain sedentary for undefined reasons.

OBJECTIVE

To compare exercise habits, perceptions about exercise, and barriers to exercise in 'low' (<3 h/week) and 'high' (≥3 h/week) exercisers with PD.

METHODS

A 48-item survey was administered to PD patients at an outpatient academic center. Chi-squared tests were used to compare the percentage differences between low- and high-exercisers with two-sided tests and a significant level of 0.05.

RESULTS

243 surveys were collected over three months; 28 were excluded due to incomplete data, leaving 215 to be analyzed. 49.3% reported 'low'-exercise and 50.7% reported 'high'-exercise. High-exercisers participated in higher intensity exercise regimens (83.4% versus 32.1%, p≤0.001). High-exercisers were more likely to start exercising after being diagnosed (54.2% versus 27.8%, p < 0.001), whereas low-exercisers were more likely to reduce their amount of exercise (40.2% versus 15.9%, p < 0.001). Low-exercisers required more motivating factors. Both groups benefited from having a significant other or a personal trainer motivate them, and both were more likely to exercise if their neurologist encouraged them. Low-exercisers reported twice as many barriers as high-exercisers (p = 0.001). Barriers that were significantly more common in low-exercisers were: lacking someone to motivate them (33.3% versus 10.5%, p < 0.001), fatigue (20.8% versus 15.2%, p = 0.005), and depression (16.7% versus 7.6%, p = 0.045).

CONCLUSIONS

There are significant differences between people with PD who exercise regularly and those who do not in terms of motivators and barriers. These findings should be considered when tailoring recommendations for PD patients to encourage exercise, and in designing future interventions.

Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review

BACKGROUND

Virtual reality (VR) has emerged as a therapeutic tool facilitating motor learning for balance and gait rehabilitation. The evidence, however, has not yet resulted in standardized guidelines. The aim of this study was to systematically review the application of VR-based rehabilitation of balance and gait in 6 neurologic cohorts, describing methodologic quality, intervention programs, and reported efficacy.

METHODS

This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. VR-based treatments of Parkinson disease, multiple sclerosis, acute and chronic poststroke, traumatic brain injury, and cerebral palsy were researched in PubMed and Scopus, including earliest available records. Therapeutic validity (CONTENT scale) and risk of bias in randomized controlled trials (RCT) (Cochrane Collaboration tool) and non-RCT (Newcastle-Ottawa scale) were assessed.

RESULTS

Ninety-seven articles were included, 68 published in 2013 or later. VR improved balance and gait in all cohorts, especially when combined with conventional rehabilitation. Most studies presented poor methodologic quality, lacked a clear rationale for intervention programs, and did not utilize motor learning principles meticulously. RCTs with more robust methodologic designs were widely recommended.

CONCLUSION

Our results suggest that VR-based rehabilitation is developing rapidly, has the potential to improve balance and gait in neurologic patients, and brings additional benefits when combined with conventional rehabilitation. This systematic review provides detailed information for developing theory-driven protocols that may assist overcoming the observed lack of argued choices for intervention programs and motor learning implementation and serves as a reference for the design and planning of personalized VR-based treatments.

REGISTRATION

PROSPERO CRD42016042051.

Trunk motion visual feedback during walking improves dynamic balance in older adults: Assessor blinded randomized controlled trial

BACKGROUND

Virtual reality and augmented feedback have become more prevalent as training methods to improve balance. Few reports exist on the benefits of providing trunk motion visual feedback (VFB) during treadmill walking, and most of those reports only describe within session changes.

RESEARCH QUESTION

To determine whether trunk motion VFB treadmill walking would improve over-ground balance for older adults with self-reported balance problems.

METHODS

40 adults (75.8 years (SD 6.5)) with self-reported balance difficulties or a history of falling were randomized to a control or experimental group. Everyone walked on a treadmill at a comfortable speed 3×/week for 4 weeks in 2 min bouts separated by a seated rest. The control group was instructed to look at a stationary bulls-eye target while the experimental group also saw a moving cursor superimposed on the stationary bulls-eye that represented VFB of their walking trunk motion. The experimental group was instructed to keep the cursor in the center of the bulls-eye. Somatosensory (monofilaments and joint position testing) and vestibular function (canal specific clinical head impulses) was evaluated prior to intervention. Balance and mobility were tested before and after the intervention using Berg Balance Test, BESTest, mini-BESTest, and Six Minute Walk.

RESULTS

There were no significant differences between groups before the intervention. The experimental group significantly improved on the BESTest (p = 0.031) and the mini-BEST (p = 0.019). The control group did not improve significantly on any measure. Individuals with more profound sensory impairments had a larger improvement on dynamic balance subtests of the BESTest.

SIGNIFICANCE

Older adults with self-reported balance problems improve their dynamic balance after training using trunk motion VFB treadmill walking. Individuals with worse sensory function may benefit more from trunk motion VFB during walking than individuals with intact sensory function.

Nintendo Wii™ Versus Xbox Kinect™ for Assisting People With Parkinson's Disease

This study investigated changes in motor and cognitive skills, anxiety levels, and quality of life perception among patients with Parkinson's Disease (PD) following training with different commercial gaming devices-Nintendo Wii™ and Xbox Kinect™. We used a quasi-experimental, simple blinded clinical trial, dividing 27 patients with PD into three equal groups of nine members: (a) Nintendo Wii™, (b) Xbox Kinect™, and (c) control group. After pretests, experimental group participants spent 10 sessions playing four games of the selected gaming device, while control group participants received no intervention. Only those engaged with the Nintendo Wii™ significantly improved their performance on single and dual task gait tests, decreased anxiety levels, and improved memory, attention, and reversibility. The control group showed no changes on any measures.

Balance and fear of falling in subjects with Parkinson's disease is improved after exercises with motor complexity

Resistance training with instability (RTI) uses exercises with high motor complexity that impose high postural control and cognitive demands that may be important for improving postural instability and fear of falling in subjects with Parkinson's disease (PD). Here, we hypothesized that: 1) RTI will be more effective than resistance training (RT) in improving balance (Balance Evaluation Systems Test [BESTest] and overall stability index [Biodex Balance System^®]) and fear of falling (Falls Efficacy Scale-International [FES-I] score) of subjects with Parkinson's disease (PD); and 2) changes in BESTest and FES-I after RTI will be associated with changes in cognitive function (Montreal Cognitive Assessment [MoCA] score - previously published) induced by RTI. Thirty-nine subjects with moderate PD were randomly assigned to a nonexercising control, RT, and RTI groups. While RT and RTI groups performed progressive RT twice a week for 12 weeks, the RTI group added progressive unstable devices to increase motor complexity of the resistance exercises. There were significant group × time interactions for BESTest, overall stability index, and FES-I scores (P < 0.05). Only RTI improved BESTest, overall stability index and FES-I scores, and RTI was more effective than RT in improving biomechanical constraints and stability in gait (BESTest sections) at post-training (P < 0.05). There were strong correlations between relative changes in BESTest and MoCA (r = 0.72, P = 0.005), and FES-I and MoCA (r = -0.75, P = 0.003) after RTI. Due to the increased motor complexity in RTI, RTI is recommended for improving balance and fear of falling, which are associated with improvement in cognitive function of PD.

Eficácia do Nintendo Wii em desfechos funcionais e de saúde de indivíduos com doença de Parkinson: uma revisão sistemática

RESUMO O objetivo deste estudo foi revisar sistematicamente a literatura sobre a eficácia do Nintendo Wii na melhora de desfechos funcionais e de saúde de indivíduos com doença de Parkinson. A revisão foi desenvolvida seguindo o PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), com buscas nas bases de dados MEDLINE, SciELO, LILACS e PEDro mediante estratégia de busca composta pela combinação dos termos “Wii”, “Doença de Parkinson”, “reabilitação” e “fisioterapia”, seguida de busca manual. Os critérios de inclusão foram: estudos experimentais ou quase-experimentais relacionados a intervenções envolvendo o uso do Nintendo Wii para melhora de desfechos funcionais em indivíduos com doença de Parkinson, publicados até fevereiro de 2016, sem restrição de idioma. A qualidade metodológica dos estudos foi avaliada pela escala PEDro. Dos 701 estudos encontrados, foram selecionados sete que atenderam aos critérios de inclusão, a maioria (57,14%) apresentava qualidade metodológica ruim e era do tipo quase-experimental. Os resultados sugerem que o uso do Wii parece eficaz para melhora de desfechos funcionais (equilíbrio, mobilidade, desempenho motor e independência) e de saúde (diminuição do risco de quedas), sendo mais consistentes os resultados para melhora do equilíbrio. São necessários estudos com melhor qualidade metodológica para o estabelecimento das evidências e, ainda, padronizações sobre os tipos de jogos, intensidade e frequência adequados para cada tipo de paciente com DP.

An Immersive Virtual Reality Platform to Enhance Walking Ability of Children with Acquired Brain Injuries

Background: Acquired brain injury (ABI) may result in lifelong impairment of physical, cognitive, and psychosocial functions. Several rehabilitative treatments are often needed to support walking recovery, thus participants’ engagement becomes a crucial aspect, especially when patients are children. In the last few years, traditional physiotherapy (PT) has been flanked by innovative technologies for rehabilitation in the fields of robotics and Virtual Reality (VR). Preliminary results have shown interesting perspectives in the use of a VR system, the GRAIL (Gait Real-time Analysis Interactive Lab), in improving walking abilities in a small group of children with ABI, although further insights are needed about its use as rehabilitative tool in the pediatric population.

Objectives: To evaluate the efficacy of a rehabilitation treatment on a GRAIL system for the improvement of walking abilities, in a group of children suffering from ABI.

Methods: 12 children with ABI (study group – SG; mean age = 12.1 ± 3.8 years old) underwent a 10-session treatment with the GRAIL, an instrumented multi-sensor platform based on immersive VR for gait training and rehabilitation in engaging VR environments. Before (T0) and at the end of the treatment (T1), the participants were assessed by means of functional scales (Gross Motor Function Measure (GMFM), Functional Assessment Questionnaire (FAQ), 6-Minute Walk Test (6minWT) and the 3D-Gait Analysis, over ground (OGA) and on GRAIL (GGA).

Results: All the participants completed the rehabilitative treatment. The functional evaluations showed an improvement in Gross Motor abilities (GMFM-88, p = 0.008), especially in standing (GMFM-D, p = 0.007) and walking (GMFM-E, p = 0.005), an increase of the endurance (6minWT, p = 0.002), and enhanced autonomy in daily life activities (FAQ, p = 0.025). OGA identified a significant decrease of the Gillette Gait Index for the impaired side and a general increase of symmetry. GGA showed improvements in spatiotemporal parameters and joints range of motion that moved towards normality and symmetry recovery.

Conclusions: A 10-session treatment with GRAIL on children with ABI led to improvements in their walking abilities and enhanced their engagement during the training. This is desirable when long life impairments are faced and children’s motor functions have to be regained and it supports the leading role that VR might have in the rehabilitation field.

The Effects of Functional Training, Bicycle Exercise, and Exergaming on Walking Capacity of Elderly Patients With Parkinson Disease: A Pilot Randomized Controlled Single-blinded Trial

OBJECTIVES

To compare the effects of functional training, bicycle exercise, and exergaming on walking capacity of elderly with Parkinson disease (PD).

DESIGN

A pilot randomized, controlled, single-blinded trial.

SETTING

A state reference health care center for elderly, a public reference outpatient clinic for the elderly.

PARTICIPANTS

Elderly individuals (≥60 years of age; N=62) with idiopathic PD (stage 2 to 3 of modified Hoehn and Yahr staging scale) according to the London Brain Bank.

INTERVENTION

The participants were randomly assigned to three groups. Group 1 (G1) participated in functional training (n=22); group 2 (G2) performed bicycle exercise (n=20), and group 3 (G3) trained with Kinect Adventures (Microsoft, Redmond, WA) exergames (n=20).

MAIN OUTCOME MEASURES

The primary outcome measure was the 6-minute walk test (6MWT); secondary outcome measures were the 10-m walk test (10MWT), sitting-rising test (SRT), body mass index, Parkinson Disease Questionnaire-39, World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), and 15-item Geriatric Depression Scale.

RESULTS

All groups showed significant improvements in 6MWT (G1 P=.008; G2 P=.001; G3 P=.005), SRT (G1 P<.001; G2 P=.001; G3 P=.003), and WHODAS 2.0 (G1 P=.018; G2 P=.019; G3 P=.041). Only G3 improved gait speed in 10MWT (P=.11). G1 (P=.014) and G3 (P=.004) improved quality of life. No difference was found between groups.

CONCLUSIONS

Eight weeks of exergaming can improve the walking capacity of elderly patients with PD. Exergame training had similar outcomes compared with functional training and bicycle exercise. The three physical exercise modalities presented significant improvements on walking capacity, ability to stand up and sit, and functionality of the participants.

Entrenamiento motor en el continuo de la realidad a la virtualidad

Introducción. La trasformación de la capacidad de movimiento de las personas es un reto que el fisioterapeuta asume como estrategia de aprendizaje motor.Objetivo. Plantear los referentes teóricos y prácticos más relevantes en el uso de ambientes terapéuticos en el continuo de la realidad a la virtualidad en el entrenamiento motor de pacientes con accidente cerebrovascular y enfermedad de Parkinson. Materiales y métodos. Revisión de la literatura que analiza y aporta de manera conceptual, en el área de la rehabilitación y la fisioterapia, información sobre entrenamiento y aprendizaje motor.Resultados. Se evidencia potencial en el uso de la realidad virtual para la rehabilitación de alteraciones del movimiento debidas a disfunciones neurológicas. Las herramientas tecnológicas propias de la realidad virtual permiten un mayor conocimiento de los resultados con respecto a las características del movimiento, lo cual ayuda a mejorar el aprendizaje motor, en comparación con el entrenamiento tradicional.Conclusiones. Se requiere objetivar el proceso de rehabilitación para medir con precisión los cambios que producen estrategias de aprendizaje en las capacidades de movimiento de las personas con deficiencias del sistema neuromuscular para generar evidencia del impacto que tienen los programas de entrenamiento motor en el continuo de la realidad a la virtualidad.

Public Perceptions Regarding Use of Virtual Reality in Health Care: A Social Media Content Analysis Using Facebook

Background

Virtual reality (VR) technology provides an immersive environment that enables users to have modified experiences of reality. VR is increasingly used to manage patients with pain, disability, obesity, neurologic dysfunction, anxiety, and depression. However, public opinion regarding the use of VR in health care has not been explored. Understanding public opinion of VR is critical to ensuring effective implementation of this emerging technology.

Objective

This study aimed to examine public opinion about health care VR using social listening, a method that allows for the exploration of unfiltered views of topics discussed on social media and online forums.

Methods

In March 2016, NBC News produced a video depicting the use of VR for patient care. The video was repackaged by NowThis, a social media news website, and distributed on Facebook by Upworthy, a news aggregator, yielding 4.3 million views and 2401 comments. We used Microsoft Excel Power Query and ATLAS.ti software (version 7.5, Scientific Software Development) to analyze the comments using content analysis and categorized the comments around first-, second-, and third-order concepts. We determined self-identified gender from the user’s Facebook page and performed sentiment analysis of the language to analyze whether the perception of VR differed by gender using a Pearson’s chi-square test.

Results

Out of the 1614 analyzable comments, 1021 (63.26%) were attributed to female Facebook users, 572 (35.44%) to male users, and 21 (1.30%) to users of unknown gender. There were 1197 comments coded as expressing a positive perception about VR (74.16%), 251 coded as expressing a negative perception and/or concern (15.56%), and 560 coded as neutral (34.70%). Informants identified 20 use cases for VR in health care, including the use of VR for pain and stress reduction; bed-bound individuals; women during labor; and patients undergoing chemotherapy, dialysis, radiation, or imaging procedures. Negative comments expressed concerns about radiation, infection risk, motion sickness, and the ubiquity of and overall dependence on technology. There was a statistically significant association between the language valence of the Facebook post and the gender of the Facebook user; men were more likely to post negative perceptions about the use of VR for health care, whereas women were more likely to post positive perceptions (P<.001).

Conclusions

Most informants expressed positive perceptions about the use of VR in a wide range of health care settings. However, many expressed concerns that should be acknowledged and addressed as health care VR continues to evolve. Our results provide guidance in determining where further research on the use of VR in patient care is needed, and offer a formal opportunity for public opinion to shape the VR research agenda.

Virtual Reality Telerehabilitation for Postural Instability in Parkinson's Disease: A Multicenter, Single-Blind, Randomized, Controlled Trial

Introduction

Telerehabilitation enables patients to access remote rehabilitation services for patient-physiotherapist videoconferencing in their own homes. Home-based virtual reality (VR) balance training has been shown to reduce postural instability in patients with Parkinson's disease (PD). The primary aim was to compare improvements in postural stability after remotely supervised in-home VR balance training and in-clinic sensory integration balance training (SIBT).

Methods

In this multicenter study, 76 PD patients (modified Hoehn and Yahr stages 2.5–3) were randomly assigned to receive either in-home VR telerehabilitation (n = 38) or in-clinic SIBT (n = 38) in 21 sessions of 50 minutes each, 3 days/week for 7 consecutive weeks. VR telerehabilitation consisted of graded exergames using the Nintendo Wii Fit system; SIBT included exercises to improve postural stability. Patients were evaluated before treatment, after treatment, and at 1-month follow-up.

Results

Analysis revealed significant between-group differences in improvement on the Berg Balance Scale for the VR telerehabilitation group (p = 0.04) and significant Time × Group interactions in the Dynamic Gait Index (p = 0.04) for the in-clinic group. Both groups showed differences in all outcome measures over time, except for fall frequency. Cost comparison yielded between-group differences in treatment and equipment costs.

Conclusions

VR is a feasible alternative to in-clinic SIBT for reducing postural instability in PD patients having a caregiver.

Different protocols for analyzing behavior and adaptability in obstacle crossing in Parkinson's disease

Imbalance and tripping over obstacles as a result of altered gait in older adults, especially in patients with Parkinson’s disease (PD), are one of the most common causes of falls. During obstacle crossing, patients with PD modify their behavior in order to decrease the mechanical demands and enhance dynamic stability. Various descriptions of dynamic traits of gait that have been collected over longer periods, probably better synthesize the underlying structure and pattern of fluctuations in gait and can be more sensitive markers of aging or early neurological dysfunction and increased risk of falls. This confirmation challenges the clinimetric of different protocols and paradigms used for gait analysis up till now, in particular when analyzing obstacle crossing. The authors here present a critical review of current knowledge concerning the interplay between the cognition and gait in aging and PD, emphasizing the differences in gait behavior and adaptability while walking over different and challenging obstacle paradigms, and the implications of obstacle negotiation as a predictor of falls. Some evidence concerning the effectiveness of future rehabilitation protocols on reviving obstacle crossing behavior by trial and error relearning, taking advantage of dual-task paradigms, physical exercise, and virtual reality have been put forward in this article.

Effects of an intensive Nordic walking intervention on the balance function and walking ability of individuals with Parkinson's disease: a randomized controlled pilot trial

BACKGROUND

Parkinson's disease (PD) is associated with impairment in balance and postural control, accompanied by a progressive reduction in the speed and amplitude of movement.

AIMS

The aim of our study was to evaluate the therapeutic effects of Nordic walking on a treadmill on the balance function and walking ability of individuals with PD.

METHOD

Twenty participants with stage 1-3 PD in the Hoehn and Yahr scale were randomly allocated to the Nordic walking training (NWT) group and treadmill training (TT) group, with ten participants per group. Measured outcomes included: the motor subscale of the Unified Parkinson's Disease Rating Scale (UPDRS-M), the Berg balance scale (BBS), the Timed Up-and-go test (TUG), the 10-meter walk test (10 MWT), and the 6-minute walk test (6 MWT).

RESULTS

Improvement on all outcome measures was identified from pre-to-post intervention for both groups (p < 0.05). Post-intervention, there was a significant between-group difference on measured outcomes (p < 0.05). The NWT group exhibited greater improvement in the UPDRS-M (p = 0.006; 95 % CI 0.825-4.374), BBS (p = 0.002; 95 % CI 1.307-5.092), TUG (p = 0.048; 95 % CI 0.028-2.582), 10 MWT (p = 0.047; 95 % CI 0.108-2.306), and 6 MWT (p = 0.003; 95 % CI 20.302-42.097) compared to the TT group.

CONCLUSIONS

Our outcomes provide evidence of the therapeutic benefit of Nordic walking on a treadmill to improve balance function and walking ability in individuals with PD.

The contribution of Nintendo Wii Fit series in the field of health: a systematic review and meta-analysis

Background

Wii Fit was originally designed as a health and fitness interactive training experience for the general public. There are, however, many examples of Wii Fit being utilized in clinical settings. This article aims to identify the contribution of Wii Fit in the field of health promotion and rehabilitation by: (1) identifying the health-related domains for which the Wii Fit series has been tested, (2) clarifying the effect of Wii Fit in those identified health-related domains and (3) quantifying this effect.

Method

A systematic literature review was undertaken. The MEDLINE database and Games for Health Journal published content were explored using the search term “Wii-Fit.” Occurrences resulting from manual searches on Google and material suggested by experts in the field were also considered. Included articles were required to have measurements from Wii Fit activities for at least one relevant health indicator. The effect of Wii Fit interventions was assessed using meta-analyses for the following outcomes: activity-specific balance confidence score, Berg balance score (BBC) and time-up-and-go test (TUG).

Findings

A total of 115 articles highlighted that the Wii Fit has been tested in numerous healthy and pathological populations. Out of these, only a few intervention studies have focused on the prevention of chronic diseases. A large proportion of the studies focus on balance training (N = 55). This systematic review highlights several potential benefits of Wii Fit interventions and these positive observations are supported by meta-analyses data (N = 25). For example, the BBC and the TUG respond to a similar extend to Wii Fit interventions compared with traditional training.

Conclusion

Wii Fit has the potential to be used as a rehabilitation tool in different clinical situations. However, the current literature includes relatively few randomized controlled trials in each population. Further research is therefore required.

Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults: Prevention, Plasticity, and Participation

Use of virtual reality (VR) and serious games (SGs) interventions within rehabilitation as motivating tools for task specific training for individuals with neurological conditions are fast-developing. Within this perspective paper we use the framework of the IV STEP conference to summarize the literature on VR and SG for children and adults by three topics: Prevention; Outcomes: Body-Function-Structure, Activity and Participation; and Plasticity. Overall the literature in this area offers support for use of VR and SGs to improve body functions and to some extent activity domain outcomes. Critical analysis of clients' goals and selective evaluation of VR and SGs are necessary to appropriately take advantage of these tools within intervention. Further research on prevention, participation, and plasticity is warranted. We offer suggestions for bridging the gap between research and practice integrating VR and SGs into physical therapist education and practice.

A 3D Computational Model of Transcutaneous Electrical Nerve Stimulation for Estimating Aβ Tactile Nerve Fiber Excitability

Tactile sensory feedback plays an important role in our daily life. Transcutaneous electrical nerve stimulation (TENS) is widely accepted to produce artificial tactile sensation. To explore the underlying mechanism of tactile sensation under TENS, this paper presented a novel 3D TENS computational model including an active Aβ tactile nerve fiber (TNF) model and a forearm finite element model with the fine-layered skin structure. The conduction velocity vs. fiber diameter and strength-duration relationships in this combined TENS model matched well with experimental data. Based on this validated TENS model, threshold current variation were further investigated under different stimulating electrode sizes with varied fiber diameters. The computational results showed that the threshold current intensity increased with electrode size, and larger nerve fibers were recruited at lower current intensities. These results were comparable to our psychophysical experimental data from six healthy subjects. This novel 3D TENS model would further guide the floorplan of the surface electrodes, and the stimulating paradigms for tactile sensory feedback.

The use of commercial video games in rehabilitation: a systematic review

The aim of this paper was to investigate the effect of commercial video games (VGs) in physical rehabilitation of motor functions. Several databases were screened (Medline, SAGE Journals Online, and ScienceDirect) using combinations of the following free-text terms: commercial games, video games, exergames, serious gaming, rehabilitation games, PlayStation, Nintendo, Wii, Wii Fit, Xbox, and Kinect. The search was limited to peer-reviewed English journals. The beginning of the search time frame was not restricted and the end of the search time frame was 31 December 2015. Only randomized controlled trial, cohort, and observational studies evaluating the effect of VGs on physical rehabilitation were included in the review. A total of 4728 abstracts were screened, 275 were fully reviewed, and 126 papers were eventually included. The following information was extracted from the selected studies: device type, number and type of patients, intervention, and main outcomes. The integration of VGs into physical rehabilitation has been tested for various pathological conditions, including stroke, cerebral palsy, Parkinson's disease, balance training, weight loss, and aging. There was large variability in the protocols used (e.g. number of sessions, intervention duration, outcome measures, and sample size). The results of this review show that in most cases, the introduction of VG training in physical rehabilitation offered similar results as conventional therapy. Therefore, VGs could be added as an adjunct treatment in rehabilitation for various pathologies to stimulate patient motivation. VGs could also be used at home to maintain rehabilitation benefits.

Nintendo Wii training on postural balance and mobility rehabilitation of adults with Parkinson's disease: a systematic review

Abstract Introduction: Postural instability affects balance control in Parkinson disease (PD) patients and increases the particular risk of falling compared with healthy older adults. Video games with not immersive virtual reality have been used in neurological disorders rehabilitation process. Objective: To evaluate the effectiveness of the video game console Nintendo Wii (NW) on postural balance and mobility treatment of adults with PD in Hoehn and Yahr stages I to III. Methods: The following databases were searched electronically on MEDLINE, Cochrane Library, PEDro, CAPES Periodic, BIREME, and LILACS databases. The search period for this review was January 2010 to June 2016. The assessment of methodological quality was performed using the PEDro Scale as reference. Results: 12 original studies were selected, but only 3 were randomized controlled trials (RCTs). Conclusion: Some of the studies analysed suggest that NW can provide improvement in balance and mobility of adults with PD. These benefits should be interpreted with caution because of the low methodological quality of the included trials, and the lack of common assessment of treatment effects. There is little evidence to ensure the effectiveness and support the inclusion of the treatment with NW of patients with PD.

Virtual reality for rehabilitation in Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disorder that is best managed by a combination of medication and regular physiotherapy. In this context, virtual reality (VR) technology is proposed as a new rehabilitation tool with a possible added value over traditional physiotherapy approaches. It potentially optimises motor learning in a safe environment, and by replicating real-life scenarios could help improve functional activities of daily living.

OBJECTIVES

The objective of this review was to summarise the current best evidence for the effectiveness of VR interventions for the rehabilitation of people with PD in comparison with 1) active interventions, and 2) passive interventions. Our primary goal was to determine the effect of VR training on gait and balance. Secondary goals included examining the effects of VR on global motor function, activities of daily living, quality of life, cognitive function, exercise adherence, and the occurrence of adverse events.

SEARCH METHODS

We identified relevant articles through electronic searches of the Cochrane Movement Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, Embase, CINAHL, the Physiotherapy Evidence Database (PEDro), online trials registers, and by handsearching reference lists. We carried out all searches up until 26 November 2016.

SELECTION CRITERIA

We searched for randomised and quasi-randomised controlled trials of VR exercise interventions in people with PD. We included only trials where motor rehabilitation was the primary goal.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched for trials that corresponded to the predefined inclusion criteria. We independently extracted and assessed all data for methodological quality. A third review author was responsible for conflict resolution when required.

MAIN RESULTS

We included 8 trials involving 263 people with PD in the review. Risk of bias was unclear or high for all but one of the included studies. Study sample sizes were small, and there was a large amount of heterogeneity between trials with regard to study design and the outcome measures used. As a result, we graded the quality of the evidence as low or very low. Most of the studies intended to improve motor function using commercially available devices, which were compared with physiotherapy. The interventions lasted for between 4 and 12 weeks.In comparison to physiotherapy, VR may lead to a moderate improvement in step and stride length (standardised mean difference (SMD) 0.69, 95% confidence interval (CI) 0.30 to 1.08; 3 studies; 106 participants; low-quality evidence). VR and physiotherapy interventions may have similar effects on gait (SMD 0.20, 95% CI -0.14 to 0.55; 4 studies; 129 participants; low-quality evidence), balance (SMD 0.34, 95% CI -0.04 to 0.71; 5 studies; 155 participants; low-quality evidence), and quality of life (mean difference 3.73 units, 95% CI -2.16 to 9.61; 4 studies; 106 participants). VR interventions did not lead to any reported adverse events, and exercise adherence did not differ between VR and other intervention arms.The evidence available comparing VR exercise with a passive control was more limited. The evidence for the main outcomes of interest was of very low quality due to the very small sample sizes of the two studies available for this comparison.

AUTHORS' CONCLUSIONS

We found low-quality evidence of a positive effect of short-term VR exercise on step and stride length. VR and physiotherapy may have similar effects on gait, balance, and quality of life. The evidence available comparing VR with passive control interventions was more limited. Additional high-quality, large-scale studies are needed to confirm these findings.