Immersive virtual reality improves movement patterns in patients after ACL reconstruction: implications for enhanced criteria-based return-to-sport rehabilitation

Effects of virtual reality rehabilitation after spinal cord injury: a systematic review and meta-analysis

BACKGROUND

Spinal cord injury (SCI) is a common neurological condition marked by damage to the spinal cord. In the field of neurological rehabilitation, virtual reality (VR) is increasingly employed for evaluating and addressing the physical limitations caused by SCI. This study aimed to describe and calculate the effect sizes of virtual reality intervention (VR) on the functional performance of SCI.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library to identify articles published before October 30, 2023, that addressed the intervention of SCI using virtual reality technology. We excluded from the meta-analysis articles that did not provide enough data to evaluate the association between virtual reality intervention and spinal cord injury. The RevMan 5.4 statistical software was used for data analysis.

RESULTS

We included 16 articles in the systematic review and pooled 9 for the meta-analysis, which were 5 randomized controlled trials (RCTs) and 4 non-RCTs, including 248 subjects. The outcome measure of the walking index for spinal cord injury, limits of stability testing and berg balance scale scores improved in non-RCTs.

CONCLUSION

VR has shown promise in enhancing walking ability and balance function in individuals with SCI. However, the existing evidence for VR interventions in SCI patients remains limited, highlighting the necessity for future studies in this area.

Virtual reality-based therapy after anterior cruciate ligament injury effectively reduces pain and improves knee function, movement patterns, and dynamic balance: A systematic review and meta-analysis

PURPOSE

Virtual reality-based therapy (VRBT) may be an effective physical therapy complement employed in the rehabilitation of patients with anterior cruciate ligament (ACL) injury. This study aims to assess the effectiveness of VRBT in improving pain, knee function, strength, proprioception, flexion range of motion (ROM), and dynamic balance after ACL injury.

METHODS

We conducted this systematic review with meta-analysis following PRISMA criteria. Since inception to June 2024, we searched in PubMed Medline, WOS, SCOPUS, CINAHL and PEDro without publication date and language restrictions. Randomised controlled trials (RCTs), comprising only patients with ACL injury, that assess the effectiveness of VRBT compared to classical interventions on the outcomes of interest were included. PEDro scale was employed to analyze the methodological quality of the RCTs included. Cohen's standardised mean difference (SMD) and its 95% confidence interval (95% CI) was used to calculate the pooled effect in meta-analyses.

RESULTS

Nine RCTs, providing data from 330 participants (26.96 ± 3.11 years, 85% males) were included. The RCTs included showed good methodological quality (PEDro scale = 6.88 points), being, performance and detection biases, the most common biases reported. Meta-analyses showed that VRBT was more effective than classical interventions in reducing pain (SMD = -1.15; 95% CI -1.85 to -0.45; p = 0.001; I2 = 0%), and increasing knee function (SMD = 1.71; 95% CI 0.93 to 2.5; p < 0.001; I2 = 0%), strength (SMD = 0.82; 95% CI 0.4-1.23; p < 0.001; I2 = 0%) and flexion ROM (SMD = 0.7; 95% CI 0.37-1.01; p < 0.001; I2 = 0%). Additionally, VRBT improved postero-medial (SMD = 0.46; 95% CI 0.01-0.9; p = 0.045; I2 = 15.1%) and postero-lateral CoP excursion (SMD = 0.75; 95% CI 0.3-1.21; p = 0.001; I2 = 0%), being effective in improving dynamic balance.

CONCLUSION

VRBT is an effective physical therapy complement to be included in the ACL's rehabilitation programmes due to reduces pain and increases knee function, strength, ROM and dynamic balance after ACL injury.

LEVEL OF EVIDENCE

Level II evidence.

Think fast, stay healthy? A narrative review of neurocognitive performance and lower extremity injury

BACKGROUND

Lower extremity (LE) injury has been problematic in athletic populations. While previous research has identified biomechanical and neuromuscular risk factors, more recent efforts have determined that neurocognitive performance (NP) may influence LE injury risk.

OBJECTIVES

To describe the present findings pertaining to the relationship between NP and LE injury. This review described potential cerebral neural mechanisms underpinning LE injury with a particular emphasis on the role of vision in sensorimotor integration. Lastly, newer technology such as stroboscopic eyewear, smartboards, and virtual/augmented reality were discussed for their utility in assessing and training NP.

METHODS

Narrative review that described NP and LE injury, as well as plausible mechanisms and training interventions.

RESULTS

NP appears to influence both LE biomechanics and LE injury risk. Athletes with worse NP demonstrated decreased knee flexion and increased frontal plane knee loading compared to better performing athletes. Most studies determined an association between NP and LE injury risk. Visual motor reaction time, processing speed, and working memory appear to be useful NP measures for identifying athletes at risk for LE injury. Various brain regions including the precuneus and lingual gyrus may be implicated as neural signatures for LE injury. While recently developed technology offer promise, far-transfer effects to LE injury risk reduction have yet to be substantially investigated.

CONCLUSIONS

NP should be considered an important component for identifying LE injury risk. Sports scientists and clinicians may consider a variety of assessments and interventions to quantify and train NP in conjunction with previously established protocols.

The Effectiveness of Virtual Reality, Augmented Reality, and Mixed Reality Rehabilitation in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Extended reality (XR), including virtual reality, augmented reality, and mixed reality, has been increasingly used in postoperative rehabilitation of total knee arthroplasty (TKA). The purpose of this systematic review and meta-analysis was to evaluate the effectiveness of XR-based rehabilitation in TKA compared to conventional rehabilitation.

METHODS

In this study, we searched PubMed (MEDLINE), Embase (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and clinicaltrials.gov from inception to February 15, 2023 for eligible studies. A total of 14 randomized controlled trials with 989 patients were included in our study. The primary outcomes were pain and function. The secondary outcomes were anxiety and quality of life. A systematic review and meta-analysis was performed.

RESULTS

The pooled data indicated XR-based rehabilitation significantly improved the visual analog scale (standardized mean difference [SMD] = -0.31, 95% Confidence Interval [CI] [-0.47 to -0.15], P = .0001), the Western Ontario and McMaster Universities Osteoarthritis Index (SMD = -0.46, 95% CI [-0.86 to -0.06], P = .02), range of motion (SMD = 0.40, 95% CI [0.09 to 0.72], P = .01), and anxiety scores (mean difference = -3.95, 95% CI [-7.76 to -0.13], P = .04) than conventional rehabilitation, but Timed Up and Go test and quality of life were similar in the 2 groups.

CONCLUSION

This systematic review and meta-analysis found XR-based rehabilitation improved pain, function, and anxiety, but not quality of life in TKA compared to conventional rehabilitation within 1 month postoperatively. Based on the pooled results, we suggested that XR-based rehabilitation may have benefit in patients' postoperative rehabilitation in TKA.

Virtual and Augmented Reality Simulators Show Intraoperative, Surgical Training, and Athletic Training Applications: A Scoping Review

PURPOSE

To review published literature to identify and evaluate the effect of virtual reality (complete immersion) and augmented reality (overlay of digital information onto the physical world) simulators on intraoperative use for orthopaedic surgeons, orthopaedic surgical education, and athletic training.

METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies, published since 2014, that evaluated the role of augmented/virtual reality on intraoperative use for orthopaedic surgeons, orthopaedic surgical education, and athletic training.

RESULTS

Virtual reality (VR) simulators provide 3-dimensional graphical simulation of the physical world, and augmented reality (AR) simulators overlay digital information onto the physical world. Simulators can include interactive features (i.e., replication of intraoperative bleeding), haptic feedback, and unrestricted task repetition, and they can record, compare, and analyze performance while being easily accessible and eliminating the need for the presence of a mentor or coach. Four studies reported on VR for intraoperative use, 47 studies on surgical education, and 10 studies on athletic training. Two studies revealed the advantages of using VR simulation during intraoperative procedures, specifically showcasing its benefits for elbow arthroscopy, while 2 studies demonstrated similar positive outcomes for hip arthroscopy. Seventeen studies demonstrated that a VR simulator could be a beneficial tool to assist in surgical education for the knee, while 12 studies found that VR simulation is a valuable tool for aiding in surgical education of shoulder arthroscopy. Ten studies demonstrated that VR simulation improves skills in the operating room. Three studies revealed that individuals with more experience exhibit superior performance on these simulators compared to those with less experience. In the realm of athletic training, 10 studies showcased the potential of VR simulation to play a significant role in athletic performance and injury rehabilitation.

CONCLUSIONS

VR simulation shows benefits in the operating room, is a valuable tool for surgical education resulting in improved skills, and can be used to enhance athletic performance and injury rehabilitation.

CLINICAL RELEVANCE

Understanding that VR simulators can improve surgical outcomes, surgical skill training, and athletic training and rehabilitation could facilitate development and adoption of this advanced technology.

Immersive virtual reality in orthopaedics-a narrative review

PURPOSE

This narrative review explores the applications and benefits of immersive virtual reality (VR) in orthopaedics, with a focus on surgical training, patient functional recovery, and pain management.

METHODS

The review examines existing literature and research studies on immersive VR in orthopaedics, analyzing both experimental and clinical studies.

RESULTS

Immersive VR provides a realistic simulation environment for orthopaedic surgery training, enhancing surgical skills, reducing errors, and improving overall performance. In post-surgical recovery and rehabilitation, immersive VR environments can facilitate motor learning and functional recovery through virtual embodiment, motor imagery during action observation, and virtual training. Additionally VR-based functional recovery programs can improve patient adherence and outcomes. Moreover, VR has the potential to revolutionize pain management, offering a non-invasive, drug-free alternative. Virtual reality analgesia acts by a variety of means including engagement and diverting patients' attention, anxiety reduction, and specific virtual-body transformations.

CONCLUSION

Immersive virtual reality holds significant promise in orthopaedics, demonstrating potential for improved surgical training, patient functional recovery, and pain management but further research is needed to fully exploit the benefits of VR technology in these areas.

Experiences of physiotherapists considering virtual reality for shoulder rehabilitation: A focus group study

Introduction

Shoulder pain is common and associated with substantial morbidity. Different treatment strategies are being prescribed with equivocal results. Virtual reality (VR) is a novel technology and emerging research suggests that VR may be a promising alternative to current treatments. Prior to effectiveness research or any large-scale introduction, VR-applications require appropriate scrutiny including feasibility- and acceptability of clinicians and patients. Therefore, the aim of this study was to collect experiences of physiotherapists after using immersive VR.

Methods

A qualitative interpretive design was used to explore physiotherapists' experiences related to the use of VR for people with shoulder symptoms. 17 physiotherapists were asked to use VR at home for five days prior to a focus group interview. Data from the focus group interviews were analyzed using a six-phase process of thematic analysis.

Results

Three main themes were identified, each divided into subthemes. The main themes were: 1. VR as an extension of contemporary physiotherapy care: physiotherapists were positive about the potential of VR and its applicability in daily care. 2. Physiotherapist uncertainties of future care using VR: participants expressed concerns about their professional identity, particularly as patients engage in independent home exercises. 3. Physiotherapist's requirements for implementation of VR: participants shared their needs for evidence regarding the effectiveness and parameters such as frequency, dosage and intensity of the VR intervention.

Conclusion

Physiotherapists were positive about VR as an intervention tool. However, they felt more knowledge is needed about parameters of VR. The findings of this study inform researchers and technology developers about optimal design of interventions and applications using VR.

Clinical Applications of Virtual Reality in Musculoskeletal Rehabilitation: A Scoping Review

(1) Background: VR is based on a virtual world that creates sounds effects and videos that replace the real environment. Arising literature shows VR efficacy in the field of neurological rehabilitation (NR) and that its use is also taking a place in musculoskeletal rehabilitation (MSR), as a treatment of various disorders that cause disability and chronic pain. (2) Aim: We discuss the role of VR in MSR, presenting its use and development on acute and chronic musculoskeletal disorders, based on the most recent literature. (3) Design and Methods: Literature searches were conducted in the databases Pubmed and Medline up to 30 September 2023. The PRISMA-Scr Checklist was followed. (4) Results: A total of 51 records were included. The analysed studies were conducted within a variety of populations, musculoskeletal disorders, settings, and VR technologies. Only a few studies could statistically affirm the efficacy of VR in MSR, as mentioned for the rehabilitation of the upper limb. Nevertheless, the observed trend is an improvement of the global perceived effect compared to traditional rehabilitation. (5) Conclusion: VR allows for the personalisation of treatment with an adaptable treatment platform, which may improve the participation of the patient and increase acceptability and adherence to long-term rehabilitation programs. We provide recommendations and suggestions for future research and use of VR in musculoskeletal rehabilitation.

Virtual training, real effects: a narrative review on sports performance enhancement through interventions in virtual reality

The present article reports a narrative review of intervention (i.e., training) studies using Virtual Reality (VR) in sports contexts. It provides a qualitative overview and narrative summary of such studies to clarify the potential benefits of VR technology for sports performance enhancement, to extract the main characteristics of the existing studies, and to inform and guide future research. Our literature search and review eventually resulted in 12 intervention studies with a pre vs. post design focused on different sports, including target and precision sports (archery, bowling, curling, darts, golf), bat/racquet and ball sports (baseball, table tennis), goal sports (football/soccer, basketball), martial arts (karate), and sport-unspecific processes such as bodily sensations and balancing. The samples investigated in the primary studies included novice, amateur, and expert athletes (total aggregated sample size N = 493). Many studies found statistically significant effects in relevant target skills following interventions in VR, often outperforming training effects in passive or active control conditions (e.g., using conventional training protocols). Therefore, interventions in VR (or extended reality) have the potential to elicit real effects in sports performance enhancement through training of motor and psychological skills and capabilities in athletes, including perception-action skills, strategic, tactical and decision-making, responding to unexpected events, and enhancing psychological resilience and mental performance under pressure. The neurocognitive mechanisms (e.g., visual search behavior, imagery), methodological aspects (e.g., adaptive training difficulty), and the issues of real-world transfer and generalizability via which these potential sports-performance-related improvements may occur are discussed. Finally, limitations of the present review, the included studies, the current state of the field in general as well as an outlook and future perspectives for research designs and directions are taken into consideration.

Athletes with a History of ACL Reconstruction Exhibit Greater Inter-Limb Asymmetry in Impact Forces During the First Landing of a Drop Vertical Jump Compared to the Second Landing

The primary objective of this study was to examine the degree of inter-limb asymmetry in impact force magnitudes and rates during the first and second landings of a drop vertical jump in adolescent athletes with a history of anterior cruciate ligament (ACL) reconstruction. We also compared the degree of asymmetry exhibited by the athletes who had undergone ACL reconstruction to a group of uninjured athletes. This study included 14 athletes who had undergone ACL reconstruction and 28 uninjured athletes, matched for age, sex, and sport. All athletes completed a double-leg drop vertical jump task. Peak vertical ground reaction forces (vGRFs) and loading rates were examined for both limbs during the first and second landings of the drop vertical jump. For the athletes who had undergone ACL reconstruction, peak vGRFs were 11.9% greater for the uninvolved limb vs. the involved limb during the first landing; however, peak vGRFs were only 2.4% greater for the uninvolved limb (vs. the involved limb) during the second landing. The athletes who had undergone ACL reconstruction exhibited greater asymmetry in peak vGRFs for the first landing compared to the uninjured athletes; however, there was no difference between the groups (ACL reconstruction, uninjured) for the second landing.

Comparison between the effect of immersive virtual reality training versus conventional rehabilitation on limb loading and functional outcomes in patients after anterior cruciate ligament reconstruction: A prospective randomized controlled trial

Purpose

Anterior cruciate ligament injury (ACL) commonly occurs during sporting events. It causes pain, instability and reduction in range of movement of the knee which results in altered balance, reduced strength as well as loading to the involved knee. The challenge to get the patient back to competitive sports level much depends on the rehabilitation process. Post ACLR rehabilitation is challenging due to the long rehabilitation time as well as boring repetitive exercises. The aim of this study is to compare between the effectiveness of using immersive virtual reality (PlayStation VR) in addition to the conventional rehabilitation as an aid in rehabilitation of patients after ACLR in terms of objective functional assessment and pain and subjective knee function scoring.

Methods

This randomised controlled trial was undertaken in a tertiary hospital in Malaysia from July 2019 until July 2020. Thirty patients were randomised into a group undergoing purely conventional rehabilitation (Group 1) and a group undergoing both conventional rehabilitation and immersive virtual reality assisted rehabilitation (Group 2). The immersive virtual reality assisted rehabilitation was started at 3 months post operatively for 3 months duration. Limb loading, balance, range of motion, functional hop tests of the knee, pain and subjective scoring of the knee with the International Knee Documentation Committee (IKDC) Scores were measured preoperatively and at 6 months.

Results

There were significant differences in terms of improvement of pain scores (p = 0.012) as well as IKDC Scores (p = 0.024) in Group 2 as compared to Group 1. However, there were no significant differences with regards to limb loading, balance, range of motion and functional hop tests of the knee (p > 0.05). No adverse events were observed during the study period.

Conclusion

Immersive virtual reality can be used as an adjunct in rehabilitation of patients after ACL reconstruction in terms of improving their pain as well as their subjective knee evaluation. Large randomised control trial is recommended to further investigate the efficacy.

Comparison of Smoothness, Movement Speed and Trajectory during Reaching Movements in Real and Virtual Spaces Using a Head-Mounted Display

Virtual reality is used in rehabilitation and training simulators. However, whether movements in real and virtual spaces are similar is yet to be elucidated. The study aimed to examine the smoothness, trajectory, and velocity of participants' movements during task performance in real and virtual space. Ten participants performed the same motor task in these two spaces, reaching for targets placed at six distinct positions. A head-mounted display (HMD) presented the virtual space, which simulated the real space environment. The smoothness of movements during the task was quantified and analysed using normalised jerk cost. Trajectories were analysed using the actual trajectory length normalised by the shortest distance to the target, and velocity was analysed using the time of peak velocity. The analysis results showed no significant differences in smoothness and peak velocity time between the two spaces. No significant differences were found in the placement of the six targets between the two spaces. Conversely, significant differences were observed in trajectory length ratio and peak velocity time, albeit with small effect sizes. This outcome can potentially be attributed to the fact that the virtual space was presented from a first-person perspective using an HMD capable of presenting stereoscopic images through binocular parallax. Participants were able to obtain physiological depth information and directly perceive the distance between the target and the effector, such as a hand or a controller, in virtual space, similar to real space. The results suggest that training in virtual space using HMDs with binocular disparity may be a useful tool, as it allows the simulation of a variety of different environments.

FitJaw Mobile, a virtual reality device applied to dentistry: An analysis based on two patient treatments

STATEMENT OF PROBLEM

Virtual reality (VR) has improved significantly in the last decade and has been applied to different fields, including medicine, dentistry, and physiotherapy. VR has been used for the innovative treatment of painful conditions, especially when traditional exercise therapies were unsuccessful because of patient noncompliance.

PURPOSE

The purpose of this study was to analyze the use of VR as an aid when using exercises to manage temporomandibular disorders (TMDs).

MATERIAL AND METHODS

Two White women diagnosed with TMDs of muscular origin (one with muscular pain and the other with reduced mouth opening) were referred to the Department of Prosthodontics of the University of Seville, where they were enrolled in an exercise program using the VR software program FitJaw Mobile. Both had been treated the previous year with an occlusal device for TMD of muscular origin, but their symptoms had not improved.

RESULTS

For both patients, the functional movement limitation and the chronic pain improved noticeably.

CONCLUSIONS

The use of VR when doing jaw exercises can improve outcomes and compliance.

Using a target as external focus of attention results in a better jump-landing technique in patients after anterior cruciate ligament reconstruction - A cross-over study

BACKGROUND

Improving jump-landing technique during rehabilitation is important and may be achieved through different feedback techniques, i.e., internal focus of attention (IF) or external focus of attention using a target (EF). However, there is a lack of evidence on the most effective feedback technique after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to investigate the potential difference in jump-landing techniques between IF and EF instructions in patients after ACLR.

METHODS

Thirty patients (12 females, mean age 23.26 ± 4.91 years) participated after ACLR. Patients were randomly assigned into two groups that each followed a different testing sequence. Patients performed a drop vertical jump-landing test after receiving instructions with varying types of focus of attention. The Landing Error Scoring System (LESS) assessed the jump-landing technique.

RESULTS

EF was associated with a significantly better LESS score (P < 0.001) compared with IF. Only EF instructions led to improvements in jump-landing technique.

CONCLUSION

Using a target as EF resulted in a significantly better jump-landing technique than IF in patients after ACLR. This indicates that increased use of EF could or might result in a better treatment outcome during ACLR rehabilitation.

Movement Regularity Differentiates Specialized and Nonspecialized Athletes in a Virtual Reality Soccer Header Task

BACKGROUND

Young athletes who specialize early in a single sport may subsequently be at increased risk of injury. While heightened injury risk has been theorized to be related to volume or length of exposure to a single sport, the development of unhealthy, homogenous movement patterns, and rigid neuromuscular control strategies may also be indicted. Unfortunately, traditional laboratory assessments have limited capability to expose such deficits due to the simplistic and constrained nature of laboratory measurement techniques and analyses.

METHODS

To overcome limitations of prior studies, the authors proposed a soccer-specific virtual reality header assessment to characterize the generalized movement regularity of 44 young female athletes relative to their degree of sport specialization (high vs low). Participants also completed a traditional drop vertical jump assessment.

RESULTS

During the virtual reality header assessment, significant differences in center of gravity sample entropy (a measure of movement regularity) were present between specialized (center of gravity sample entropy: mean = 0.08, SD = 0.02) and nonspecialized center of gravity sample entropy: mean = 0.10, SD = 0.03) groups. Specifically, specialized athletes exhibited more regular movement patterns during the soccer header than the nonspecialized athletes. However, no significant between-group differences were observed when comparing participants' center of gravity time series data from the drop vertical jump assessment.

CONCLUSIONS

This pattern of altered movement strategy indicates that realistic, sport-specific virtual reality assessments may be uniquely beneficial in exposing overly rigid movement patterns of individuals who engage in repeated sport specialized practice.

Interventions for increasing return to sport rates after an anterior cruciate ligament reconstruction surgery: A systematic review

Background

An injury followed by surgery poses many challenges to an athlete, one of which is rehabilitation, with the goal of returning to sport. While total restoration of physical abilities is a primary goal for most athletes, psychosocial factors also play an important role in the success of an athlete's return to sport (RTS). The purpose of this review was to examine the effectiveness of exercise and psychosocial interventions on RTS rates, which might be one of the most important outcomes for elite athletes.

Methods

To carry out this review, PubMed, SAGE Journals, Web of Science, SPORTDiscus, ScienceDirect, and Google Scholar databases were searched from inception to July 2022. The inclusion criteria consisted exercise or psychosocial intervention for athletes after anterior cruciate ligament reconstruction (ACLR), with reporting RTS rates as an outcome.

Results

From 1032 identified articles, four reports (N = 130) met inclusion criteria, all of which examined the recovery after ACLR. The mean MINORS score for the included studies was 16.3 ± 6.1, of which non-comparative studies scored 11.0 ± 1.4, while comparative studies scored 21.5 ± 0.7. There were consistent findings for benefits of exercise and psychosocial interventions on RTS rates. Return to preinjury rates in the reviewed studies vary between 63 and 95% with lower % observed in female athletes and with shorter follow-up. Interventional studies reporting RTS rates with a larger sample size and longer follow-up are needed.

Conclusion

Physical and psychological function, as well as social support can be influenced by appropriate interventions, indicating future work on rehabilitation programs for return to preinjury might consider taking the holistic approach addressing those.

Comparison of Performance and Movement Kinematics of Virtual Reality Practice with Real-World Practice in the Dart-Throwing Skill

Background: Researchers are pursuing the enhancement of sensorimotor skills through the application of virtual reality (VR) in the sports environment. Objectives: This study aimed to compare the performance and kinematics of VR with real-world dart-throwing. Methods: Twenty-four healthy junior high school boy students participated (aged = 13.66, SD = 0.48) in this semi-experimental study in the year of 2017. We examined mean radial and bivariate variable errors as the performance variables. The maximum flexion angle, release time angle, and angular velocity was examined as the kinematic variables. Standard dartboard, the Xbox360, the Kinect, and a high-speed camera (sampling at 240 Hz) were used to measure the performance and kinematics characteristics of upper limb motion. We used Kinovea 0.8.26 and MATLAB R2015b to analyze videos and data smoothing. One-way MANOVA was used to analyze variables. Results: The results revealed (P = 0.211) no significant differences between VR and real world (RW) training in acquisition and retention outcomes, F (4, 19) = 1.618. In addition, kinematic dependent variables (P = 0.414) had no significant difference between groups, F (6, 17) = 1.077. Conclusions: These findings achieved the same results in performance and kinematics of dart-throwing by VR intervention in the RW context. Basic similarities between VR and RW movement patterns in the same task bring motor skills improvement and transfer of learning.

Linking Pain and Motor Control: Conceptualization of Movement Deficits in Patients With Painful Conditions

When people experience or expect pain, they move differently. Pain-altered movement strategies, collectively described here as pain-related movement dysfunction (PRMD), may persist well after pain resolves and, ultimately, may result in altered kinematics and kinetics, future reinjury, and disability. Although PRMD may manifest as abnormal movements that are often evident in clinical assessment, the underlying mechanisms are complex, engaging sensory-perceptual, cognitive, psychological, and motor processes. Motor control theories provide a conceptual framework to determine, assess, and target processes that contribute to normal and abnormal movement and thus are important for physical therapy and rehabilitation practice. Contemporary understanding of motor control has evolved from reflex-based understanding to a more complex task-dependent interaction between cognitive and motor systems, each with distinct neuroanatomic substrates. Though experts have recognized the importance of motor control in the management of painful conditions, there is no comprehensive framework that explicates the processes engaged in the control of goal-directed actions, particularly in the presence of pain. This Perspective outlines sensory-perceptual, cognitive, psychological, and motor processes in the contemporary model of motor control, describing the neural substrates underlying each process and highlighting how pain and anticipation of pain influence motor control processes and consequently contribute to PRMD. Finally, potential lines of future inquiry-grounded in the contemporary model of motor control-are outlined to advance understanding and improve the assessment and treatment of PRMD.

IMPACT

This Perspective proposes that approaching PRMD from a contemporary motor control perspective will uncover key mechanisms, identify treatment targets, inform assessments, and innovate treatments across sensory-perceptual, cognitive, and motor domains, all of which have the potential to improve movement and functional outcomes in patients with painful conditions.

XR (Extended Reality: Virtual Reality, Augmented Reality, Mixed Reality) Technology in Spine Medicine: Status Quo and Quo Vadis

In recent years, with the rapid advancement and consumerization of virtual reality, augmented reality, mixed reality, and extended reality (XR) technology, the use of XR technology in spine medicine has also become increasingly popular. The rising use of XR technology in spine medicine has also been accelerated by the recent wave of digital transformation (i.e., case-specific three-dimensional medical images and holograms, wearable sensors, video cameras, fifth generation, artificial intelligence, and head-mounted displays), and further accelerated by the COVID-19 pandemic and the increase in minimally invasive spine surgery. The COVID-19 pandemic has a negative impact on society, but positive impacts can also be expected, including the continued spread and adoption of telemedicine services (i.e., tele-education, tele-surgery, tele-rehabilitation) that promote digital transformation. The purpose of this narrative review is to describe the accelerators of XR (VR, AR, MR) technology in spine medicine and then to provide a comprehensive review of the use of XR technology in spine medicine, including surgery, consultation, education, and rehabilitation, as well as to identify its limitations and future perspectives (status quo and quo vadis).

Perceptions of professional soccer coaches, support staff and players toward virtual reality and the factors that modify their intention to use it

A small evidence base supports the use of virtual reality in professional soccer, yet there is a lack of information available on perceptions and desire to use the technology from those employed at professional soccer clubs. Therefore, the aim of the study was to compare and quantify the perceptions of virtual reality use in soccer, and to model behavioural intentions to use this technology. This study surveyed the perceptions of coaches, support staff, and players in relation to their knowledge, expectations, influences and barriers of using virtual reality via an internet-based questionnaire. To model behavioural intention, modified questions and constructs from the Unified Theory of Acceptance and Use of Technology were used, and the model was analysed through partial least squares structural equation modelling. Respondents represented coaches and support staff (n = 134) and players (n = 64). All respondents generally agreed that virtual reality should be used to improve tactical awareness and cognition, with its use primarily in performance analysis and rehabilitation settings. Generally, coaches and support staff agreed that monetary cost, coach buy-in and limited evidence base were barriers towards its use. In a sub-sample of coaches and support staff without access to virtual reality (n = 123), performance expectancy was the strongest construct in explaining behavioural intention to use virtual reality, followed by facilitating conditions (i.e., barriers) construct which had a negative association with behavioural intention. Virtual reality has the potential to be a valuable technology within professional soccer although several barriers exist that may prevent its widespread use.

Virtual reality-based rehabilitation in patients following total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Physical therapy is regarded as an essential aspect in achieving optimal outcomes following total knee arthroplasty (TKA). The coronavirus disease 2019 (COVID-19) pandemic has made face-to-face rehabilitation inaccessible. Virtual reality (VR) is increasingly regarded as a potentially effective option for offering health care interventions. This systematic review and meta-analysis investigate VR-based rehabilitation's effectiveness on outcomes following TKA.

METHODS

From inception to May 22, 2021, PubMed/Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, Scopus, PsycINFO, Physiotherapy Evidence Database, China National Knowledge Infrastructure, and Wanfang were comprehensively searched to identify randomized controlled trials (RCTs) evaluating the effect of VR-based rehabilitation on patients following TKA according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Eight studies were included in the systematic review, and seven studies were included in the meta-analysis. VR-based rehabilitation significantly improved visual analog scale (VAS) scores within 1 month (standardized mean difference [SMD]: -0.44; 95% confidence interval [CI]: -0.79 to -0.08, P = 0.02), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) within 1 month (SMD: -0.71; 95% CI: -1.03 to -0.40, P < 0.01), and the Hospital for Special Surgery Knee Score (HSS) within 1 month and between 2 months and 3 months (MD: 7.62; 95% CI: 5.77 to 9.47, P < 0.01; MD: 10.15; 95% CI: 8.03 to 12.27, P < 0.01; respectively) following TKA compared to conventional rehabilitation. No significant difference was found in terms of the Timed Up and Go (TUG) test.

CONCLUSIONS

VR-based rehabilitation improved pain and function but not postural control following TKA compared to conventional rehabilitation. More high-quality RCTs are needed to prove the advantage of VR-based rehabilitation. As the COVID-19 pandemic continues, it is necessary to promote this rehabilitation model.

Clinical Effect of Virtual Reality Technology on Rehabilitation Training of Sports Injury

In order to make most patients recover most of their limb functions after rehabilitation training, virtual reality technology is an emerging human-computer interaction technology, which uses the computer and the corresponding application software to build the virtual reality environment. Completing the training tasks in the virtual environment attracts the patients to conduct repeated training in the game and task-based training mode and gradually realizes the rehabilitation training goals. For the rehabilitation population with certain exercise ability, the kinematics of human upper limbs is mainly analyzed, and the virtual reality system based on HTC VIVE is developed. The feasibility and work efficiency of the upper limb rehabilitation training system were verified by experiments. Adult volunteers who are healthy and need rehabilitation training to participate in the experiment were recruited, and experimental data were recorded. The virtual reality upper limb rehabilitation system was a questionnaire. By extracting the motion data, the system application effect is analyzed and evaluated by the simulation diagram. Follow-up results of rehabilitation training showed that the average score of healthy subjects was more than 4 points and 3.8 points per question. Therefore, it is feasible to perform upper limb rehabilitation training using the HTC VIVE virtual reality rehabilitation system.

Kinetic Asymmetry During a Repetitive Tuck Jump Task in Athletes with a History of Anterior Cruciate Ligament Reconstruction

BACKGROUND

Athletes who have undergone anterior cruciate ligament reconstruction typically exhibit relatively high/rapid loading of their uninvolved limb during bilateral landing and jumping (vs. their limb that underwent reconstruction), which may place their uninvolved limb at risk for injury. However, previous studies have only examined forces and loading rates for tasks involving an isolated land-and-jump.

PURPOSE

The purpose of this study was to examine bilateral landing and jumping kinetics during performance of a repetitive tuck jump task in athletes who had undergone anterior cruciate ligament reconstruction and completed rehabilitation.

STUDY DESIGN

Cross-sectional study.

METHODS

Nine athletes (four males, five females) participated in this study. All participants had undergone successful unilateral anterior cruciate ligament reconstruction, had completed post-operative rehabilitation, and were in the process of completing return-to-sport testing. Athletes performed a repetitive tuck jump task for 10 seconds, while ground reaction forces were recorded for their uninvolved and involved limbs via separate force platforms. Two-way analysis of variance, for within-subjects factors of limb and cycle, was performed for the impact forces, loading rates, and propulsive forces from the first five land-and-jump cycles completed.

RESULTS

There was not a limb-by-cycle interaction effect or main effect of cycle for the impact forces, loading rates, or propulsive forces; however, there was a main effect of limb for the impact forces (F(1, 8) = 14.64; p=0.005), loading rates (F(1, 8) = 5.60; p=0.046), and propulsive forces (F(1, 8) = 10.38; p=0.012). Impact forces, loading rates, and propulsive forces were higher for the uninvolved limb, compared to the involved limb, over the five land-and-jump cycles analyzed.

CONCLUSION

The athletes in this study consistently applied higher and more rapid loads to their uninvolved limb over multiple land-and-jump cycles. This may help to explain the relatively high injury rates for the uninvolved limb in athletes who have returned to sport following anterior cruciate ligament reconstruction.

Kinetic measurement system use in individuals following anterior cruciate ligament reconstruction: a scoping review of methodological approaches

Purpose

Our primary objectives were to (1) describe current approaches for kinetic measurements in individuals following anterior cruciate ligament reconstruction (ACLR) and (2) suggest considerations for methodological reporting. Secondarily, we explored the relationship between kinetic measurement system findings and patient-reported outcome measures (PROMs).

Methods

We followed the PRISMA extension for scoping reviews and Arksey and O’Malley’s 6-stage framework. Seven electronic databases were systematically searched from inception to June 2020. Original research papers reporting parameters measured by kinetic measurement systems in individuals at least 6-months post primary ACLR were included.

Results

In 158 included studies, 7 kinetic measurement systems (force plates, balance platforms, pressure mats, force-measuring treadmills, Wii balance boards, contact mats connected to jump systems, and single-sensor insoles) were identified 4 main movement categories (landing/jumping, standing balance, gait, and other functional tasks). Substantial heterogeneity was noted in the methods used and outcomes assessed; this review highlighted common methodological reporting gaps for essential items related to movement tasks, kinetic system features, justification and operationalization of selected outcome parameters, participant preparation, and testing protocol details. Accordingly, we suggest considerations for methodological reporting in future research. Only 6 studies included PROMs with inconsistency in the reported parameters and/or PROMs.

Conclusion

Clear and accurate reporting is vital to facilitate cross-study comparisons and improve the clinical application of kinetic measurement systems after ACLR. Based on the current evidence, we suggest methodological considerations to guide reporting in future research. Future studies are needed to examine potential correlations between kinetic parameters and PROMs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-021-00397-0.

Current perspectives and clinical practice of physiotherapists on assessment, rehabilitation, and return to sport criteria after anterior cruciate ligament injury and reconstruction. An online survey of 538 physiotherapists

OBJECTIVES

To evaluate the perspectives and clinical practice of physiotherapists regarding rehabilitation after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Online survey.

SETTING

Survey platform.

PARTICIPANTS

Greek physiotherapists.

OUTCOME MEASURES

The survey consisted of 7 sections: participant demographics, importance of ACLR rehabilitation, clinical measurements, practice, criteria to progress rehabilitation, return to running and return to sport.

RESULTS

Significant variability in measures and criteria used for clinical decision-making were found including: limb symmetry in strength and function, knee range of motion and effusion, progression, and return to sport criteria. The majority of the practitioners (28.3%) extrapolate knee strength from hop capacity. Return to running ranged from 3 to 5 months post-operatively reflecting that this was tied to physical capacities, not time from surgery. 70.0% of the Greek physiotherapists would allow return to sport ≤9 months after ACLR. Agreement was found in using: physical measures, function, and dynamic stability in ACLR rehabilitation, but the mode and interpretation varied substantially. Less than 29.0% of the physiotherapists reported using patient-reported outcome measures in their decision-making.

CONCLUSION

Current ACLR rehabilitation practices in Greece are largely not aligned with the contemporary scientific evidence and guidelines.

Virtual reality promotes greater improvements than video-stimulation screen on perceptual-cognitive skills in young soccer athletes

Background The literature has shown the positive effect of virtual reality (VR) in percepto-cognitive skills. However, the literature lacks findings about at what extent VR would be better than video. Purpose This study aimed to analyze the chronic effect of VR and video-stimulation screen training on passing decision-making, visual search behavior, and inhibitory control performance in young soccer athletes. Method A total of 26 young soccer players underwent an 8-week training protocol after being randomly assigned to the VR (n = 13) or video-screen (VID, n = 13) group. Passing decision-making, visual search behavior, and inhibitory control performance were measured before and after both interventions. Results A group x time interaction was found for decision-making performance (p < 0.01) and visual search behavior (p < 0.01). Both groups improved both decision-making performance (p < 0.01) and visual search behavior (p < 0.01); however, greater improvements were verified in VR (p < 0.01). Both VR and VID improved inhibitory control (p < 0.01), but no group interaction effect was observed (p > 0.05). Conclusion Our results suggest that VR leads to greater improvements in decision-making and visual search behavior in young soccer athletes than VID.

Design and implementation of typical dynamic traffic scenes based on virtual reality technology

It is of great significance to simulate dangerous traffic environment with vehicle driving simulator for reducing and preventing road traffic accidents. Firstly, a typical dynamic traffic scene was obtained and designed by using genetic algorithm, then a chaotic algorithm based on computer virtual reality scene was proposed. Finally, a dynamic scene in urban road scene was taken as an example, of which the simulation was designed and implemented by using virtual reality technology. The results show that the virtual operating environment of driver micro-traffic simulation can be effectively constructed with the combination of virtual reality technology and dynamic traffic scene.

Virtual Reality Systems for Upper Limb Motor Function Recovery in Patients With Spinal Cord Injury: Systematic Review and Meta-Analysis

BACKGROUND

Patients with spinal cord injury (SCI) usually present with different motor impairments, including a deterioration of upper limb motor function (ULMF), that limit their performance of activities of daily living and reduce their quality of life. Virtual reality (VR) is being used in neurological rehabilitation for the assessment and treatment of the physical impairments of this condition.

OBJECTIVE

A systematic review and meta-analysis was conducted to evaluate the effectiveness of VR on ULMF in patients with SCI compared with conventional physical therapy.

METHODS

The search was performed from October to December 2019 in Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Medline, Physiotherapy Evidence Database (PEDro), PubMed, and Cochrane Central Register of Controlled Trials. The inclusion criteria of selected studies were as follows: (1) comprised adults with SCI, (2) included an intervention with VR, (3) compared VR intervention with conventional physical therapy, (4) reported outcomes related to ULMF, and (5) was a controlled clinical trial. The Cochrane Collaboration's tool was used to evaluate the risk of bias. The RevMan 5.3 statistical software was used to obtain the meta-analysis according to the standardized mean difference (SMD) and 95% CIs.

RESULTS

Six articles were included in this systematic review. Four of them contributed information to the meta-analysis. A total of 105 subjects were analyzed. All of the studies used semi-immersive or nonimmersive VR systems. The statistical analysis showed nonsignificant results for the Nine-Hole Peg Test (SMD -0.93, 95% CI -1.95 to 0.09), muscle balance test (SMD -0.27, 95% CI -0.82 to 0.27), Motricity Index (SMD 0.16, 95% CI -0.37 to 0.68), Jebsen-Taylor Hand Function Test (JTHFT) subtests (writing, SMD -0.10, 95% CI -4.01 to 3.82; simulated page turning, SMD -0.99, 95% CI -2.01 to 0.02; simulated feeding, SMD -0.64, 95% CI -1.61 to 0.32; stacking checkers, SMD 0.99, 95% CI -0.02 to 2.00; picking up large light objects, SMD -0.42, 95% CI -1.37 to 0.54; and picking up large heavy objects, SMD 0.52, 95% CI -0.44 to 1.49), range of motion of shoulder abduction/adduction (SMD -0.23, 95% CI -1.48 to 1.03), shoulder flexion/extension (SMD 0.56, 95% CI -1.24 to 2.36), elbow flexion (SMD -0.36, 95% CI -1.14 to 0.42), elbow extension (SMD -0.21, 95% CI -0.99 to 0.57), wrist extension (SMD 1.44, 95% CI -2.19 to 5.06), and elbow supination (SMD -0.18, 95% CI -1.80 to 1.44). Favorable results were found for the JTHFT subtest picking up small common objects (SMD -1.33, 95% CI -2.42 to -0.24).

CONCLUSIONS

The current evidence for VR interventions to improve ULMF in patients with SCI is limited. Future studies employing immersive systems to identify the key aspects that increase the clinical impact of VR interventions are needed, as well as research to prove the benefits of the use of VR in the rehabilitation of patients with SCI in the clinical setting.

The Application of Virtual Reality in Cervical Spinal Surgery: A Review

In recent years, clinicians have used virtual reality (VR) to simulate real-world environments for medical purposes. The use of VR systems in the field of cervical spine surgery can lead to effective surgical training programs without causing harm to patients. Moreover, both imaging and VR can be used before surgery to assist preoperative surgical planning. VR devices have a variety of built-in motion sensors, therefore kinematic data can be recorded while users are wearing VR devices and performing some actions for the evaluation of cervical spine activity and exercise ability. Therapists have also applied VR to cervical spine rehabilitation and showed good results. At present, the application of VR systems in cervical spine surgery has great potential, but current research is insufficient. Here, we review the latest advancements in VR technology used in cervical spine surgery and discuss potential directions for future work.

Virtual reality-based action observation facilitates the acquisition of body-powered prosthetic control skills

Background

Regular body-powered (BP) prosthesis training facilitates the acquisition of skills through repeated practice but requires adequate time and motivation. Therefore, auxiliary tools such as indirect training may improve the training experience and speed of skill acquisition. In this study, we examined the effects of action observation (AO) using virtual reality (VR) as an auxiliary tool. We used two modalities during AO: three-dimensional (3D) VR and two-dimensional (2D) computer tablet devices (Tablet). Each modality was tested from first- and third-person perspectives.

Methods

We studied 40 healthy right-handed participants wearing a BP prosthesis simulator on their non-dominant hands. The participants were divided into five groups based on combinations of the different modalities and perspectives: first-person perspective on VR (VR1), third-person perspective on VR (VR3), first-person perspective on a tablet (Tablet1), third-person perspective on a tablet (Tablet3), and a control group (Control). The intervention groups observed and imitated the video image of prosthesis operation for 10 min in each of two sessions. We evaluated the level of immersion during AO using the visual analogue scale. Prosthetic control skills were evaluated using the Box and Block Test (BBT) and a bowknot task (BKT).

Results

In the BBT, there were no significant differences in the amount of change in the skills between the five groups. In contrast, the relative changes in the BKT prosthetic control skills in VR1 (p < 0.001, d = 3.09) and VR3 (p < 0.001, d = 2.16) were significantly higher than those in the control group. Additionally, the immersion scores of VR1 (p < 0.05, d = 1.45) and VR3 (p < 0.05, d = 1.18) were higher than those of Tablet3. There was a significant negative correlation between the immersion scores and the relative change in the BKT scores (Spearman’s r_s = − 0.47, p < 0.01).

Conclusions

Using the BKT of bilateral manual dexterity, VR-based AO significantly improved short-term prosthetic control acquisition. Additionally, it appeared that the higher the immersion score was, the shorter the execution time of the BKT task. Our findings suggest that VR-based AO training may be effective in acquiring bilateral BP prosthetic control, which requires more 3D-based operation.

A comparison of the effects of plyometric and virtual training on physical and functional performance: a randomized, controlled, clinical trial

BACKGROUND

This study compared the effects of plyometric training (PT) and virtual training (VT) on physical and functional performance.

METHODS

Fifty-five moderately-trained women participated in this randomized, controlled, prospective study. The subjects were randomly assigned to VT (N.=20), PT (N.=18), and control (CG, N.=17) groups. The VT was performed using the Your Body Shape Fitness Evolved 2012^™ exergame in an Xbox360/Kinetic^™ environment. The PT was based on the methods used in previous studies. Both interventions were performed 3 times per week for 8 weeks. Participants in the CG were not submitted to any type of intervention. Physical performance (fitness and athleticism levels) was assessed using the Nike+ Kinetic Training^™ exergame in an Xbox360/Kinetic^™ environment. Functional performance was assessed using the shuttle run (SR), triple hop test (THT), and six-meter timed hop test (STHT).

RESULTS

Postintervention fitness and athleticism levels were significantly greater in VT (P<0.001 and P=0.009) and in PT (P<0.001 and P=0.003) than baselines values. Only VT postintervention fitness level was significantly greater compared to CG (P=0.03). Postintervention SR values were significantly lower than baselines values in all groups (P<0.001). VT (P=0.08) and PT (P=0.006) postintervention values were significantly lower compared to CG. Postintervention THT values were significantly greater than baselines values in VT and PT (P<0.001). VT (P=0.04 - dominant limb) and PT (P=0.003 - dominant limb; and P=0.03 - non-dominant limb) postintervention values were significantly greater compared to CG. Postintervention STHT values were significantly lower than baselines values in VT (P<0.001), PT (P<0.001) and CG (P=0.01-0.02). PT postintervention dominant (P=0.01) and non-dominant (P=0.03) limb values were significantly lower compared to CG.

CONCLUSIONS

Both VT and PT are beneficial for improving physical and functional performance. Therefore, VT might be a new tool that can be used for physical exercise practice and conditioning training in moderately-trained women.

Effectiveness of Virtual Reality on Functional Performance after Spinal Cord Injury: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

A spinal cord injury (SCI) usually results in a significant limitation in the functional outcomes, implying a challenge to the performance of activities of daily living. The main aim of this study is to analyze the effectiveness of virtual reality to improve functional performance in patients with SCI. The search was performed between October and December 2019 in Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), PubMed, Scopus, Web of Science, and Embase. The methodological quality of the studies was evaluated through the PEDro scale, and the risk of bias was evaluated with the Cochrane collaboration’s tool. Seven articles were included in this systematic review, and five of them in the meta-analysis. Statistical analysis showed favorable results for functional performance in control group performing conventional therapy, measured by the functional independence measure (standardized mean difference (SMD)= −0.70; 95% confidence interval: −1.25 to −0.15). Results were inconclusive for other outcomes. Most studies have not shown beneficial effects on functional performance compared with conventional physical therapy. The results obtained showed that virtual reality may not be more effective than conventional physical therapy in improving functional performance in patients with SCI.

Digital Medicine in Rheumatology: Challenges and Opportunities

The exponential growth in technology has had a significant effect on the practice of medicine and will likely transform the practice of medicine. In this article, the authors review select technologies that are already influencing the practice of rheumatology. Social media Websites such as Twitter are now important sources of information and discussion for health care professionals interested in rheumatology. Virtual reality is an innovative technology with great potential for acute and chronic pain management. The authors also review several low-cost technology alternatives to commonly used tools used in rheumatology.

Is Virtual Reality Effective in Orthopedic Rehabilitation? A Systematic Review and Meta-Analysis

BACKGROUND

Virtual reality (VR) is an interactive technology that allows customized treatment and may help in delivering effective person-centered rehabilitation.

PURPOSE

The purpose of this review was to systematically review and critically appraise the controlled clinical trials that investigated VR effectiveness in orthopedic rehabilitation.

DATA SOURCES

Pubmed, CINAHL, Embase, PEDro, REHABDATA, and Sage publications were searched up to September 2018. In addition, manual searching and snowballing using Scopus and Web of Science were done.

STUDY SELECTION

Two reviewers screened studies for eligibility first by title and abstract and then full text.

DATA EXTRACTION

Articles were categorized into general or region-specific (upper limbs, lower limbs, and spine) orthopedic disorders. Study quality was assessed using the Evaluation Guidelines for Rating the Quality of an Intervention Study scoring. Meta-analysis quantified VR effectiveness, compared with no treatment, in back pain.

DATA SYNTHESIS

Nineteen studies were included in the quality assessment. The majority of the studies were of moderate quality. Fourteen studies showed that VR did not differ compared with exercises. Compared with the no-treatment control, 5 studies favored VR and 3 other studies showed no differences. For low back pain, the meta-analysis revealed no significant difference between VR and no-treatment control (n = 116; standardized mean difference = -0.21; 95% confidence interval = -0.58 to 0.15).

LIMITATIONS

Limitations included heterogeneity in interventions and the outcome measures of reviewed studies. Only articles in English were included.

CONCLUSION

The evidence of VR effectiveness is promising in chronic neck pain and shoulder impingement syndrome. VR and exercises have similar effects in rheumatoid arthritis, knee arthritis, ankle instability, and post-anterior cruciate reconstruction. For fibromyalgia and back pain, as well as after knee arthroplasty, the evidence of VR effectiveness compared with exercise is absent or inconclusive.

Using video simulations and virtual reality to improve decision-making skills in basketball

A large body of literature supports the effectiveness of using video simulations to improve decision-making skills in invasion sports. However, whether these improvements are transferable (from the laboratory to the court/field) and generalizable (from trained to untrained plays) remains unknown. In addition, it remains to be determined whether presenting the video simulations using virtual reality provides an added-value. To investigate these questions, varsity-level basketball players underwent four training sessions during which they observed video clips of basketball plays presented either on a computer screen (CS group) or using a virtual reality headset (VR group). A third group watched footage from NCAA playoff games on a computer screen (CTRL group). Decision-making was assessed on-court before and after the training sessions using two types of plays: "trained" plays (presented during the CS and VR training sessions) and "untrained" plays (presented only during the on-court tests). When facing the trained plays in the posttest, both VR and CS groups significantly outperformed the CTRL group. In contrast, when facing the untrained plays, the VR group outperformed both the CS and CTRL groups. Our results indicate that CS training leads to transferable but non-generalized decision-making gains while VR training leads to transferable and generalized gains.

Virtual reality interventions for balance prevention and rehabilitation after musculoskeletal lower limb impairments in young up to middle-aged adults: A comprehensive review on used technology, balance outcome measures and observed effects

BACKGROUND

Balance training is an important aspect in prevention and rehabilitation of musculoskeletal lower limb injuries. Virtual reality (VR) is a promising addition or alternative to traditional training. This review aims to provide a comprehensive overview of VR technology and games employed for balance prevention and rehabilitation, balance outcome measures, and effects for both balance prevention and balance rehabilitation following musculoskeletal lower limb impairments.

METHODS

A systematic literature search was conducted in electronic databases to identify all related articles with a longitudinal study design on VR, balance, and prevention or musculoskeletal rehabilitation of the lower limbs in adult subjects between 19 and 65 years.

RESULTS

Eleven articles concerning balance prevention and five articles regarding balance rehabilitation were included. All studies used screen-based VR and off-the-shelf gaming consoles with accompanying games. The Star Excursion Balance Test (SEBT) was the most frequently used outcome measure. Two studies found positive effects of VR balance training in healthy adults, while none reported negative effects. None of the included studies showed a significant difference in balance performance after a VR balance rehabilitation intervention compared to traditional balance training.

CONCLUSION

Few studies have been published concerning musculoskeletal balance rehabilitation and balance prevention in healthy adult subjects. However, the studies published have shown that VR exercises are equally effective compared to traditional balance training for both domains of application. As there is large variability between studies, recommendations for future research are given to prospectively investigate the use of VR technology for balance training.

Immersion of virtual reality for rehabilitation - Review

Virtual reality (VR) shows promise in the application of healthcare and because it presents patients an immersive, often entertaining, approach to accomplish the goal of improvement in performance. Eighteen studies were reviewed to understand human performance and health outcomes after utilizing VR rehabilitation systems. We aimed to understand: (1) the influence of immersion in VR performance and health outcomes; (2) the relationship between enjoyment and potential patient adherence to VR rehabilitation routine; and (3) the influence of haptic feedback on performance in VR. Performance measures including postural stability, navigation task performance, and joint mobility showed varying relations to immersion. Limited data did not allow a solid conclusion between enjoyment and adherence, but patient enjoyment and willingness to participate were reported in care plans that incorporates VR. Finally, different haptic devices such as gloves and controllers provided both strengths and weakness in areas such movement velocity, movement accuracy, and path efficiency.

Poor knee function after ACL reconstruction is associated with attenuated landing force and knee flexion moment during running

PURPOSE

Poor knee function after anterior cruciate ligament reconstruction (ACLR) may increase the risk of future knee symptoms and knee osteoarthritis via abnormal knee joint loading patterns, particularly during high-impact activity. This study aimed to assess the relationship between poor self-reported or clinically measured knee function and knee moments/vertical ground reaction force (vGRF) in individuals following ACLR.

METHODS

61 participants (mean 16.5 ± 3 months following ACLR, 23 women) completed a patient-reported knee function questionnaire and three hop tests (% of uninvolved limb). Participants were divided into satisfactory and poor knee function groups (poor < 85% patient-reported knee function and/or < 85% hop test symmetry). The knee biomechanics of both groups were assessed with three-dimensional motion analysis during the stance phase of overland running at self-selected speeds, and the association between knee function and knee moments was assessed using analysis of covariance with running speed as a covariate.

RESULTS

Participants with poor knee function (n = 30) ran with significantly smaller peak knee flexion moments (moderate effect size 0.7, p = 0.03) and significantly smaller peak vGRFs (large effect size 1.0, p = 0.002) compared to those with satisfactory knee function (n = 31). No significant differences were observed for knee adduction and knee external rotation moments or knee kinematics.

CONCLUSION

Individuals following ACLR with poor self-reported knee function and/or hop test performance demonstrate knee moments during running that may be associated with lower knee joint contact forces. These findings provide greater understanding of the relationship between knee biomechanics during running and clinical assessments of knee function.

LEVEL OF EVIDENCE

III. Cross-sectional study.

"I never made it to the pros…" Return to sport and becoming an elite athlete after pediatric and adolescent anterior cruciate ligament injury-Current evidence and future directions

The management of anterior cruciate ligament (ACL) injuries in the skeletally immature and adolescent patient remains an area of controversy in sports medicine. This study, therefore, summarizes and discusses the current evidence related to treating pediatric and adolescent patients who sustain an ACL injury. The current literature identifies a trend towards ACL reconstruction as the preferred treatment option for ACL injuries in the young, largely justified by the risk of further structural damage to the knee joint. Worryingly, a second ACL injury is all too common in the younger population, where almost one in every three to four young patients who sustain an ACL injury and return to high-risk pivoting sport will go on to sustain another ACL injury. The clinical experience of these patients emphasizes the rarity of an athlete who makes it to elite level after a pediatric or adolescent ACL injury, with or without reconstruction. If these patients are unable to make it to an elite level of sport, treatment should possibly be modified to take account of the risks associated with returning to pivoting and strenuous sport. The surveillance of young athletes may be beneficial when it comes to reducing injuries. Further research is crucial to better understand specific risk factors in the young and to establish independent structures to allow for unbiased decision-making for a safe return to sport after ACL injury. Level of evidence V.

Clinical course and recommendations for patients after anterior cruciate ligament injury and subsequent reconstruction: A narrative review

Almost all athletes who have suffered an anterior cruciate ligament (ACL) injury expect a full return to sports at the same pre-injury level after ACL reconstruction (ACLR). Detailed patient information on the reasonable outcomes of the surgery may be essential to improve patient satisfaction.

Pre-operative rehabilitation before ACLR should be considered as an addition to the standard of care to maximise functional outcomes after ACLR.

We propose an optimised criterion-based rehabilitation programme within a biopsychosocial framework.

No benchmark exists for evaluating return-to-sport (RTS) readiness after ACLR. Therefore, the authors propose a multi-factorial RTS test battery. A combination of both physical and psychological elements should be included in the RTS test battery.

There is need for shared decision-making regarding RTS.

Cite this article: EFORT Open Rev 2017;2:410-420. DOI: 10.1302/2058-5241.2.170011

Emerging Utility of Virtual Reality as a Multidisciplinary Tool in Clinical Medicine

OBJECTIVE

Among the more recent products borne of the evolution of digital technology, virtual reality (VR) is gaining a foothold in clinical medicine as an adjunct to traditional therapies. Early studies suggest a growing role for VR applications in pain management, clinical skills training, cognitive assessment and cognitive therapy, and physical rehabilitation.

MATERIALS AND METHODS

To complete a review of the literature, we searched PubMed and MEDLINE databases with the following search terms: "virtual reality," "procedural medicine," "oncology," "physical therapy," and "burn." We further limited our search to publications in the English language. Boolean operators were used to combine search terms.

RESULTS

The included search terms yielded 97 potential articles, of which 45 were identified as meeting study criteria, and are included in this review. These articles provide data, which strongly support the hypothesis that VR simulations can enhance pain management (by reducing patient perception of pain and anxiety), can augment clinical training curricula and physical rehabilitation protocols (through immersive audiovisual environments), and can improve clinical assessment of cognitive function (through improved ecological validity).

CONCLUSION

Through computer-generated, life-like digital landscapes, VR stands to change the current approach to pain management, medical training, neurocognitive diagnosis, and physical rehabilitation. Additional studies are needed to help define best practices in VR utilization, and to explore new therapeutic uses for VR in clinical practice.

Development of a test battery to enhance safe return to sports after anterior cruciate ligament reconstruction

PURPOSE

There is a lack of consensus regarding the appropriate criteria for releasing patients to return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR). A test battery was developed to support decision-making.

METHODS

Twenty-eight patients (22 males and 6 females) with a mean age of 25.4 ± 8.2 years participated and were 6.5 ± 1.0 months post-ACLR. All patients followed the same rehabilitation protocol. The test battery used consisted of the following: isokinetic test, 3 hop tests and the jump-landing task assessed with the LESS. The isokinetic tests and single-leg hop tests were expressed as a LSI (involved limb/uninvolved limb × 100 %). In addition, patients filled out the IKDC and ACL-Return to Sport after Injury (ACL-RSI) scale. RTS criteria to pass were defined as a LSI > 90 % on isokinetic and hop tests, LESS < 5, ACL-RSI > 56 and a IKDC within 15th percentile of healthy subjects.

RESULTS

Two out of 28 patients passed all criteria of the test protocol. The pass criterion for the LESS < 5 was reached by 67.9 % of all patients. For the hop tests, 78.5 % of patients passed LSI > 90 % for SLH, 85.7 % for TLH and 50 % for the SH. For the isokinetic test, 39.3 % of patients passed criteria for LSI peak torque quadriceps at 60°/s, 46.4 % at 180°/s and 42.9 at 300°/s. In total, 35.7 % of the patients passed criterion for the peak torque at 60°/s normalized to BW (>3.0 Nm) for the involved limb. The H/Q ratio at 300°/s > 55 % for females was achieved by 4 out of 6 female patients, and the >62.5 % criterion for males was achieved by 75 %. At 6 months post-ACLR, 85.7 % of the patients passed the IKDC score and 75 % the ACL-RSI score >56 criteria.

CONCLUSION

The evidence emerging from this study suggests that the majority of patients who are 6 months after ACLR require additional rehabilitation to pass RTS criteria. The RTS battery described in this study may serve as a framework for future studies to implement multivariate models in order to optimize the decision-making regarding RTS after ACLR with the aim to reduce incidence of second ACL injuries.

LEVEL OF EVIDENCE

III.