Effects of Virtual Reality vs Conventional Balance Training on Balance and Falls in People With Multiple Sclerosis: A Randomized Controlled Trial

Home-Based Balance Training on Balance and Mobility in Persons With Multiple Sclerosis: A Systematic Review and Meta-analysis

OBJECTIVES

To (1) examine the effects of home-based balance training on balance and mobility outcomes; (2) evaluate comparable effects between home- and center-based balance training; (3) determine the effects of different levels of supervision on treatment effects; and (4) investigate dose-response relationships of home-based balance training on balance and mobility performance in persons with multiple sclerosis (MS).

DATA SOURCES

Literature searches were conducted in MEDLINE, EMBASE, PsycINFO, SPORTSDiscus, and CINAHL in April 2023. Other literature sources included website and citation searches.

STUDY SELECTION

The study included randomized controlled trials of home-based balance training that included balance and mobility outcomes in persons with MS.

DATA EXTRACTION

Data extracted from each study included (1) number of participants; (2) dropout rate; (3) sex; (4) MS phenotype; (5) age; (6) Expanded Disability Status Scale (range); (7) exercise dose; (8) level of supervision; (9) type of intervention; (10) exercise progression; (11) type of control; and (12) outcomes measures. For the meta-analysis, mean and SD of the balance and mobility outcomes in both the intervention and control groups were used. The methodological quality of included studies was evaluated by Tool for the Assessment of Study Quality and Reporting in Exercise.

DATA SYNTHESIS

Eleven studies were identified in this systematic review and meta-analysis. Each balance and mobility outcome was standardized using Hedges' g.

CONCLUSIONS

This meta-analysis revealed comparable results between home- and center-based balance training in terms of balance and mobility improvement. There was also no evidence for the superiority of home-based balance training over no training except for static steady-state balance. This study revealed that training sessions (>36 sessions) and total exercise time (>1100min) were significant moderators for overall balance improvements. Results also indicated that, when designing future interventions, at least an indirect level of supervision (eg, weekly or biweekly phone/video calls) is warranted to maintain adherence.

Effects of exercise in people with multiple sclerosis: a systematic review and meta-analysis

Background

A growing body of studies have examined the effect of exercise in people with multiple sclerosis (MS), while findings of available studies were conflicting. This meta-analysis aimed to explore the effects of exercise on balance, walking ability, walking endurance, fatigue, and quality of life in people with MS.

Methods

We searched PubMed, Web of Science, Scopus, and Cochrane databases, through March 1, 2024. Inclusion criteria were: (1) RCTs; (2) included an intervention and control group; (3) had people with MS as study subjects; (4) had balance, walking ability, walking endurance, fatigue, or quality of life as the outcome measures. Exclusion criteria were: (1) non-English publications; (2) animal model publications; (3) review articles; and (4) conference articles. A meta-analysis was conducted to calculate weighted mean difference (WMD) and 95% confidence interval (CI). Cochrane risk assessment tool and Physiotherapy Evidence Database (PEDro) scale were used to evaluate the methodological quality of the included studies.

Results

Forty studies with a total of 56 exercise groups (n = 1,300) and 40 control groups (n = 827) were eligible for meta-analysis. Exercise significantly improved BBS (WMD, 3.77; 95% CI, 3.01 to 4.53, P < 0.00001), TUG (WMD, -1.33; 95% CI, -1.57 to -1.08, P < 0.00001), MSWS-12 (WMD, -2.57; 95% CI, -3.99 to -1.15, P = 0.0004), 6MWT (WMD, 25.56; 95% CI, 16.34 to 34.79, P < 0.00001), fatigue (WMD, -4.34; 95% CI, -5.83 to -2.84, P < 0.00001), and MSQOL-54 in people with MS (WMD, 11.80; 95% CI, 5.70 to 17.90, P = 0.0002) in people with MS. Subgroup analyses showed that aerobic exercise, resistance exercise, and multicomponent training were all effective in improving fatigue in people with MS, with resistance exercise being the most effective intervention type. In addition, a younger age was associated with a larger improvement in fatigue. Furthermore, aerobic exercise and multicomponent training were all effective in improving quality of life in people with MS, with aerobic exercise being the most effective intervention type.

Conclusion

Exercise had beneficial effects in improving balance, walking ability, walking endurance, fatigue, and quality of life in people with MS. Resistance exercise and aerobic exercise are the most effective interventions for improving fatigue and quality of life in people with MS, respectively. The effect of exercise on improving fatigue was associated with the age of the participants, with the younger age of the participants, the greater the improvement in fatigue.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=371056, identifier: CRD42022371056.

The Interplay of Sports and Nutrition in Neurological Health and Recovery

This comprehensive review explores the dynamic relationship between sports, nutrition, and neurological health. Focusing on recent clinical advancements, it examines how physical activity and dietary practices influence the prevention, treatment, and rehabilitation of various neurological conditions. The review highlights the role of neuroimaging in understanding these interactions, discusses emerging technologies in neurotherapeutic interventions, and evaluates the efficacy of sports and nutritional strategies in enhancing neurological recovery. This synthesis of current knowledge aims to provide a deeper understanding of how lifestyle factors can be integrated into clinical practices to improve neurological outcomes.

A custom-built step exergame training programme to prevent falls in people with multiple sclerosis: A multicentre randomised controlled trial

BACKGROUND

Cognitive-motor step training can improve stepping, balance and mobility in people with multiple sclerosis (MS), but effectiveness in preventing falls has not been demonstrated.

OBJECTIVES

This multisite randomised controlled trial aimed to determine whether 6 months of home-based step exergame training could reduce falls and improve associated risk factors compared with usual care in people with MS.

METHODS

In total, 461 people with MS aged 22-81 years were randomly allocated to usual care (control) or unsupervised home-based step exergame training (120 minutes/week) for 6 months. The primary outcome was rate of falls over 6 months from randomisation. Secondary outcomes included physical, cognitive and psychosocial function at 6 months and falls over 12 months.

RESULTS

Mean (standard deviation (SD)) weekly training duration was 70 (51) minutes over 6 months. Fall rates did not differ between intervention and control groups (incidence rates (95% confidence interval (CI)): 2.13 (1.57-2.69) versus 2.24 (1.35-3.13), respectively, incidence rate ratio: 0.96 (95% CI: 0.69-1.34, p = 0.816)). Intervention participants performed faster in tests of choice-stepping reaction time at 6 months. No serious training-related adverse events were reported.

CONCLUSION

The step exergame training programme did not reduce falls among people with MS. However, it significantly improved choice-stepping reaction time which is critical to ambulate safely in daily life environment.

Validity, reliability, and responsiveness of Persian version of mini-balance evaluation system test among ambulatory people with multiple sclerosis

BACKGROUND AND PURPOSE

Mini-Balance Evaluation Systems Test (mini-BESTest) is a widely used measure to assess balance impairments. This study aimed to assess the validity, reliability, responsiveness, and minimal clinically important change (MCIC) of the Persian mini-BESTest among ambulatory People with Multiple Sclerosis (PwMS).

METHODS

Fifty ambulatory PwMS participated in this study. Persian mini-BESTest validated against Berg Balance Scale (BBS) and Timed-Up and Go (TUG) with/without a cognitive task. To assess the reliability, the Persian mini-BESTest was re-administered for a sample of 30 participants after 1 week. Also, 32 PwMS were tested before and after a 4-week of balance and gait training to assess the responsiveness.

RESULTS

No floor/ceiling effect was found for the mini-BESTest total score. There were significant excellent correlations (p < .001) between mini-BESTest and BBS (r = 0.71), TUG (r = -0.76), and cognitive TUG (r = -0.73). No strong correlations were observed between the subscales (r = 0.37-0.55). Test-retest reliability and internal consistency of Persian mini-BESTest total score were excellent, with Intra-class Correlation Coefficient (ICC3,1 and Cronbach's alpha level of 0.89 and 0.80, respectively. The minimal detectable change was 4 points. The Persian mini-BESTest had acceptable responsiveness (AUC = 0.83), and MCIC was 5 points.

CONCLUSION

The Persian mini-BESTest is a valid, reliable, and responsive measure of balance performance in Iranian ambulatory PwMS.

Exercise-based gaming in patients with multiple sclerosis: A systematic review and meta-analysis

Background

Multiple sclerosis presents a significant burden, with balance disturbances impacting patients' daily living. Conventional therapies have been supplemented with technological advancements like virtual reality (VR) and exergaming, providing engaging, multisensory rehabilitation options.

Objective

This study aimed to synthesize evidence on exergaming's role in multiple sclerosis treatment, particularly to evaluate the impact of exergaming on cognitive, motor, and psychological outcomes in patients with multiple sclerosis.

Methods

A systematic review and subsequent meta-analysis design were employed. An extensive search was conducted up to June 2023 across five electronic databases - Web of Science, Scopus, PubMed, Cochrane, and EMBASE. The data extraction process from the selected studies was conducted independently. The risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool 1 (ROB1) and the National Institutes of Health (NIH) assessment tool. Continuous outcomes were consolidated as mean differences (MD) with 95% confidence intervals (CIs). Meta-analyses were performed using RevMan ver. 5.4.

Results

Out of 1,029 studies, 27 were included for meta-analysis. There were no significant differences in cognitive outcomes between the exergaming and the no-intervention group or the Conventional Physiotherapy and Rehabilitation interventions (CPRh) subgroups. However, the Symbol Digit Modalities Test (SDMT) showed a statistically significant difference in favor of exergaming in the no-intervention subgroup (MD = 5.40, 95% CI [0.08, 10.72], p = 0.05). In motor outcomes, exergaming only demonstrated better results in the 6-minute walking test compared to the no-intervention group (MD = 25.53, 95% CI [6.87, 44.19], p = 0.007). The Berg Balance Scale score in both studied subgroups and the Timed Up and Go (TUG) test in the no-intervention group favored exergaming. In terms of psychological outcomes, the Beck Depression Inventory did not reveal any significant differences, while the Modified Fatigue Impact Scale (MFIS) score favored exergaming in the CPRh subgroup.

Conclusion

Exergaming shows promise for enhancing cognitive and motor functions, motivation, adherence, and quality of life in MS patients, which is beneficial for nurses. It can be tailored to individual preferences and easily conducted at home, potentially serving as a viable alternative to traditional rehab programs, especially during relapses. However, further research is necessary to fully understand its optimal and lasting benefits.

Effects of home-based virtual reality telerehabilitation system in people with multiple sclerosis: A randomized controlled trial

BACKGROUND AND OBJECTIVE

Multiple sclerosis is an inflammatory and neurodegenerative disorder of the central nervous system that can lead to severe motor disability. The aim of this study was to verify the health care effects of an integrated telerehabilitation approach involving dual-domains (motor and cognitive) in people with multiple sclerosis using a virtual reality rehabilitation system compared to a home-based conventional rehabilitative intervention usual care for patient-relevant outcomes (motor, cognitive and participation).

METHODS

This multicentre interventional, randomized controlled trial included 70 participants with multiple sclerosis, 35 in the telerehabilitation group (30 sessions of home-based virtual reality rehabilitation system training, five sessions for week each lasting 45 min) and 35 in the usual care group (30 sessions of conventional treatment, five sessions for week). Participants completed the assessment of motor, cognitive and participation outcomes at baseline and after 6 weeks of treatment.

RESULTS

In total, 63.3% of the telerehabilitation group exhibited improvement in the physical domain of the quality of life (p = 0.045). The telerehabilitation group showed greater improvement than the usual care group in Mini-BESTest domains of balance (p = 0.014), postural control (p = 0.024), and dynamic walking (p = 0.020) at post-treatment. Higher adherence was registered for telerehabilitation compared with usual care (86.67% vs. 80.0%).

DISCUSSION

This study provides evidence that people with multiple sclerosis can benefit from telerehabilitation treatment in the physical domain of the quality of life and motor symptoms. Moreover, considering the persistent COVID-19 emergency, telerehabilitation can represent an effective telemedicine solution for safely delivering effective rehabilitation care to people with multiple sclerosis.

TRIAL REGISTRATION NUMBER AND TRIAL REGISTER

This trial was registered at ClinicalTrials.gov (NCT03444454).

An Internet- and Kinect-Based Multiple Sclerosis Fitness Intervention Training With Pilates Exercises: Development and Usability Study

BACKGROUND

Balance impairments are common in people with multiple sclerosis (MS), with reduced ability to maintain position and delayed responses to postural adjustments. Pilates is a popular alternative method for balance training that may reduce the rapid worsening of symptoms and the increased risk of secondary conditions (eg, depression) that are frequently associated with physical inactivity.

OBJECTIVE

In this paper, we aimed to describe the design, development, and usability testing of MS Fitness Intervention Training (MS-FIT), a Kinect-based tool implementing Pilates exercises customized for MS.

METHODS

MS-FIT has been developed using a user-centered design approach (design, prototype, user feedback, and analysis) to gain the target user's perspective. A team composed of 1 physical therapist, 2 game programmers, and 1 game designer developed the first version of MS-FIT that integrated the knowledge and experience of the team with MS literature findings related to Pilates exercises and balance interventions based on exergames. MS-FIT, developed by using the Unity 3D (Unity Technologies) game engine software with Kinect Sensor V2 for Windows, implements exercises for breathing, posture, and balance. Feedback from an Italian panel of experts in MS rehabilitation (neurologists, physiatrists, physical therapists, 1 statistician, and 1 bioengineer) and people with MS was collected to customize the tool for use in MS. The context of MS-FIT is traveling around the world to visit some of the most important cities to learn the aspects of their culture through pictures and stories. At each stay of the travel, the avatar of a Pilates teacher shows the user the exercises to be performed. Overall, 9 people with MS (n=4, 44% women; mean age 42.89, SD 11.97 years; mean disease duration 10.19, SD 9.18 years; Expanded Disability Status Scale score 3.17, SD 0.75) were involved in 3 outpatient user test sessions of 30 minutes; MS-FIT's usability was assessed through an ad hoc questionnaire (maximum value=5; higher the score, higher the usability) evaluating easiness to use, playability, enjoyment, satisfaction, and acceptance.

RESULTS

A user-centered design approach was used to develop an accessible and challenging tool for balance training. All people with MS (9/9, 100%) completed the user test sessions and answered the ad hoc questionnaire. The average score on each item ranged from 3.78 (SD 0.67) to 4.33 (SD 1.00), which indicated a high usability level. The feedback and suggestions provided by 64% (9/14) of people with MS and 36% (5/14) of therapists involved in the user test were implemented to refine the first prototype to release MS-FIT 2.0.

CONCLUSIONS

The participants reported that MS-FIT was a usable tool. It is a promising system for enhancing the motivation and engagement of people with MS in performing exercise with the aim of improving their physical status.

Balance rehabilitation for patients with Multiple Sclerosis using a Kinect®-based virtual training program

BACKGROUND

Patients with multiple sclerosis (MS) often experience balance issues during physical activities. Traditional rehabilitation exercises such as stretching, resistance, and aerobic training have been found to be effective, but can be repetitive and tedious, leading to reduced patient motivation and adherence. Furthermore, direct supervision by a therapist is not always possible.

METHODS

The aim of this study was to develop and evaluate the effectiveness of a virtual training program incorporating visual feedback from the Kinect® sensor in male patients with multiple sclerosis. Forty-five participants, with an age range of 22-56 years (mean age = 39), were randomly assigned to one of three equal groups, including two experimental groups and one control group. The experimental groups participated in eight-week exercise interventions, with each session lasting 20 to 30 min and occurring three times per week. In contrast, the control group received no interventions. Within the experimental groups, one was exposed to conventional balance exercises, whereas the other engaged in the proposed virtual training program. Both of these groups undertook three balance exercises, namely the single-foot stance, lunge maneuvers, and arm/leg stretching routines. The assessment encompassed diverse facets of balance, including parameters of 10 Meter Walk Time, Berg Balance Scale, Static Balance Score, and Time-Up and Go Scale, as well as the quality of life, gauged through the Multiple Sclerosis Quality of Life (MSQOL)-54 Questionnaire. The effect of test variables was investigated using analysis of covariance (ANCOVA), while the independent samples t-test was used to check for significant differences among the groups. The effects of the groups were compared using a paired samples t-test.

RESULTS

The findings revealed that both rehabilitation programs positively affected the dependent variables compared to the control group. However, the significant difference between the pre-test and post-test scores of the experimental groups indicated the effectiveness of the proposed program compared to the traditional method.

CONCLUSIONS

Entertaining virtual training programs utilizing visual feedback can be effective for rehabilitating patients with MS. The proposed method enables patients to perform rehabilitation exercises at home with high motivation, while accurate information about the treatment process are provided to the therapist.

Adaptation strategies and neurophysiological response in early-stage Parkinson's disease: BioVRSea approach

Introduction

There is accumulating evidence that many pathological conditions affecting human balance are consequence of postural control (PC) failure or overstimulation such as in motion sickness. Our research shows the potential of using the response to a complex postural control task to assess patients with early-stage Parkinson's Disease (PD).

Methods

We developed a unique measurement model, where the PC task is triggered by a moving platform in a virtual reality environment while simultaneously recording EEG, EMG and CoP signals. This novel paradigm of assessment is called BioVRSea. We studied the interplay between biosignals and their differences in healthy subjects and with early-stage PD.

Results

Despite the limited number of subjects (29 healthy and nine PD) the results of our work show significant differences in several biosignals features, demonstrating that the combined output of posturography, muscle activation and cortical response is capable of distinguishing healthy from pathological.

Discussion

The differences measured following the end of the platform movement are remarkable, as the induced sway is different between the two groups and triggers statistically relevant cortical activities in α and θ bands. This is a first important step to develop a multi-metric signature able to quantify PC and distinguish healthy from pathological response.

The effect of virtual reality technology on anti-fall ability and bone mineral density of the elderly with osteoporosis in an elderly care institution

OBJECTIVE

To explore the impact of virtual reality (VR) training on anti-fall ability and bone mineral density (BMD) among elderly patients admitted to a healthcare institution.

METHODS

People (aged 50) with osteoporosis in an elderly care institution in Anhui Province June 2020 to October 2021 were selected and randomly divided into VR group (n = 25) and control group (n = 25). In VR group, the virtual reality rehabilitation training system was used for training, while control group was treated with traditional fall prevention exercise intervention. The changes of Berg Balance Scale (BBS), timed up and go test (TUGT), functional gait assessment (FGA), bone mineral density (BMD) and falls during 12 months of training were compared between the two groups.

RESULTS

BBS and FGA were positively correlated with BMD of the lumbar vertebrae and femoral neck, and TUGT was negatively correlated with BMD of the lumbar vertebrae and femoral neck. After 12 months of training, the BBS score, TUGT evaluation and FGA evaluation of the two groups were significantly improved compared with those prior to training (P < 0.05). However, there was no significant difference in the lumbar spine and femoral neck BMD between the two groups 6 months after the intervention. The femoral neck and lumbar spine BMD of the VR group improved, and it was significantly higher than that of the control group 12 months after the intervention. Nevertheless, there was no significant difference in terms of the incidence of adverse events between the two groups.

CONCLUSION

VR training can improve anti-fall ability and increase femoral neck and lumbar spine BMD and can effectively prevent and reduce the risk of injury among elderly people with osteoporosis.

Virtual Reality Applications in Neurorehabilitation: Current Panorama and Challenges

Central Nervous System Diseases are a leading cause of disability worldwide, posing significant social and economic burdens for patients, their families, caregivers, and society as a whole [...].

Virtual reality-based therapy improves balance and reduces fear of falling in patients with multiple sclerosis. a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aims to conduct a meta-analysis to assess the effect of virtual reality-based therapy (VRBT) on balance dimensions and fear of falling in patients with multiple sclerosis (PwMS). Secondarily, to determine the most recommendable dose of VRBT to improve balance.

METHODS

PubMed Medline, Web of Science, Scopus, CINAHL and PEDro were screened, without publication date restrictions, until September 30th, 2021. Randomized controlled trials (RCTs) comparing the effectiveness of VRBT against other interventions in PwMS were included. Functional and dynamic balance, confidence of balance, postural control in posturography, fear of falling and gait speed were the variables assessed. A meta-analysis was performed by pooling the Cohen's standardized mean difference (SMD) with 95% confidence interval (95% CI) using Comprehensive Meta-Analysis 3.0.

RESULTS

Nineteen RCTs, reporting 858 PwMS, were included. Our findings reported that VRBT is effective in improving functional balance (SMD = 0.8; 95%CI 0.47 to 1.14; p < 0.001); dynamic balance (SMD = - 0.3; 95%CI - 0.48 to - 0.11; p = 0.002); postural control with posturography (SMD = - 0.54; 95%CI - 0.99 to - 0.1; p = 0.017); confidence of balance (SMD = 0.43; 95%CI 0.15 to 0.71; p = 0.003); and in reducing fear of falling (SMD = - 1.04; 95%CI - 2 to - 0.07; p = 0.035); but not on gait speed (SMD = - 0.11; 95%CI: - 0.35 to 0.14; p = 0.4). Besides, the most adequate dose of VRBT to achieve the greatest improvement in functional balance was at least 40 sessions, five sessions per week and 40-45 min per sessions; and for dynamic balance, it would be between 8 and 19 weeks, twice a week and 20-30 min per session.

CONCLUSION

VRBT may have a short-term beneficial role in improving balance and reducing fear of falling in PwMS.

Effects of exergaming on cognition, lower limb functional coordination, and stepping time in people with multiple sclerosis: a randomized controlled trial

PURPOSE

To compare the effects of exergaming versus conventional exercises on cognition, lower-limb functional coordination, and stepping time in people with multiple sclerosis (PwMS).

METHODS

Thirty-six PwMS were randomly assigned to either intervention (n = 18) or control (n = 18) group and received 18 training sessions during six weeks. The intervention group performed exergames that required multidirectional timed-stepping, weight-shifting, and walking while the control group performed conventional matched exercises. Trail making test (TMT part A, B; TMT-A, TMT-B, TMT B-A), six-spot step test (SSST), and choice stepping reaction time (CSRT-including reaction time (RT), movement time (MVT), and total response time (TRT)) were assessed pre- and post-intervention (short-term), and after three-month follow-up (mid-term).

RESULTS

The intervention group showed faster TMT-B (p = 0.003) and TMT B-A (p = 0.002) at post-intervention and faster SSST at both post-intervention (p = 0.002) and follow-up (p = 0.04). The CSRT components showed no between-group differences at post-intervention; however, at follow-up, the intervention group had lower TRT (p = 0.046) and MVT (p = 0.015). TMT-A and RT had no significant between-group differences.

CONCLUSIONS

In short-term, exergames led to more improvements in complex attention, executive function, and lower-limb functional coordination comparing to the matched conventional exercises. In mid-term, exergaming was more effective for improving stepping time and lower-limb functional coordination. However, the two approaches did not show any superiority over each other for improving simple attention and RT.Implications for rehabilitationWhen designed properly, exergames have great potential to improve attention and executive function of people with multiple sclerosis (PwMS), at least in the short-term.Exergames seem like an appropriate option for improving lower limb coordination and decreasing choice stepping response time among PwMS in the mid-term.Exergames do not have superiority in improving the choice stepping reaction time compared to their matched conventional treatment.

Treadmill training with virtual reality to enhance gait and cognitive function among people with multiple sclerosis: a randomized controlled trial

BACKGROUND

Motor and cognitive impairments impact the everyday functioning of people with MS (pwMS). The present randomized controlled trial (RCT) evaluated the benefits of a combined motor-cognitive virtual reality training program on key motor and cognitive symptoms and related outcomes in pwMS.

METHODS

In a single-blinded, two-arm RCT, 124 pwMS were randomized into a treadmill training with virtual reality (TT + VR) group or a treadmill training alone (TT) (active-control) group. Both groups received three training sessions per week for 6 weeks. Dual-tasking gait speed and cognitive processing speed (Symbol Digit Modalities Test, SDMT, score) were the primary outcomes. Secondary outcomes included additional tests of cognitive function, mobility, and patient-reported questionnaires. These were measured before, after, and 3 months after training.

RESULTS

Gait speed improved (p < 0.005) in both groups, similarly, by about 10 cm/s. The TT + VR group (n = 53 analyzed per-protocol) showed a clinically meaningful improvement of 4.4 points (95% CI 1.9-6.8, p = 0.001) in SDMT, compared to an improvement of only 0.8 points in the TT (n = 51 analyzed per-protocol) group (95% CI 0.9-2.5 points, p = 0.358) (group X time interaction effect p = 0.027). Furthermore, TT + VR group-specific improvements were seen in depressive symptoms (lowered by 31%, p = 0.003), attention (17%, p < 0.001), and verbal fluency (11.6% increase, p = 0.002).

DISCUSSION

These findings suggest that both TT and TT + VR improve usual and dual-task gait in pwMS. Nonetheless, a multi-modal approach based on VR positively impacts multiple aspects of cognitive function and mental health, more than seen after treadmill-treading alone. Trial registered at ClinicalTrials.Gov NCT02427997.

Unwrapping the "black box" of balance training in people with multiple sclerosis - A descriptive systematic review of intervention components, progression, and intensity

BACKGROUND

Delineating the specific components of the existing balance training interventions in people with multiple sclerosis (PwMS) may contribute to a framework for future design and reporting of such interventions. Thus, we aimed to systematically synthesize how balance training frequency, intensity, time, type, duration, and progression are reported in balance training interventions for PwMS.

METHODS

A systematic literature search was conducted in Medline, Embase, Web of Science, and Cinahl. Search terms were MS, postural balance, walking, gait, and randomized/quasi-randomized controlled or clinical trials. Articles including ambulatory PwMS and interventions designed to challenge the balance control system were eligible. Two investigators screened, selected, and extracted data independently. Data on study characteristics such as design, population, and balance training content were extracted. Categorization of balance training based on balance control components was performed.

RESULTS

We included 40 studies grouped under five balance training categories. Balance interventions were well described regarding frequency, session time, and duration, but only two interventions described training intensity, and no systematic, gradual progression approach was reported for balance training adaptation over time. However, the balance training interventions included many sensory and motor components of the balance control system. Still, little focus was on reactive motor strategies, vestibular sense, and cognitive dual-tasking.

CONCLUSIONS

Existing balance training interventions in PwMS primarily consist of practicing sensory and motor strategies. Future balance training interventions are encouraged to systematically monitor individual advancements in balance training adaptations and to apply the progressive overload principle (i.e. continuous increase in balance exercise stimulus over time). Furthermore, we suggest that balance training in PwMS is performed with high intensity near an individual's balance capacity limits. Finally, individualized balance training is recommended to cover all relevant components of balance control using the proposed framework.

Dropout rate in randomised controlled trials of balance and gait rehabilitation in multiple sclerosis: is it expected to be different for virtual reality-based interventions? A systematic review with meta-analysis and meta-regression

To assess and meta-analyse the pooled dropout rate from the randomised control trilas that use virtual reality for balance or gait rehabilitation in people with multiple sclerosis. A systematic review of randomised control trials with meta-analysis and meta-regressions was performed. A search was conducted in PubMed, Scopus, Web of Science, the Physiotherapy Evidence Database, the Cochrane Database, CINHAL, LILACS, ScienceDirect, and ProQuest. It was last updated in July 2022. After the selection of studies, a quality appraisal was carried out using the PEDro Scale and the Revised Cochrane risk-of-bias tool for randomised trials. A descriptive analysis of main characteristics and dropout information was performed. An overall proportion meta-analysis calculated the pooled dropout rate. Odds ratio meta-analysis compared the dropout likelihood between interventions. The meta-regression evaluated the influence of moderators related to dropout. Sixteen studies with 656 participants were included. The overall pooled dropout rate was 6.6% and 5.7% for virtual reality and 9.7% in control groups. The odds ratio (0.89, p = 0.46) indicated no differences in the probability of dropouts between the interventions. The number, duration, frequency, and weeks of sessions, intervention, sex, multiple sclerosis phenotype, Expanded Disability Status Scale score, and PEDro score were not moderators (p > 0.05). Adverse events were not reported and could not be analysed as moderators. Dropouts across the virtual reality and control comparators were similar without significant differences. Nonetheless, there is a slight trend that could favour virtual reality. Standardisation in reporting dropouts and adverse events is recommended for future trials. PROSPERO database, registration number ID CRD42021284989.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10055-022-00733-4.

Cognition and proprioception in persons with multiple sclerosis and healthy controls: Nascent findings

BACKGROUND

Although proprioception and cognitive dysfunction are commonly associated with balance impairment and fall risk in persons with multiple sclerosis (MS), the relationship between cognitive functioning and a quantitative measure of proprioception has not been examined in MS.

OBJECTIVE

The primary goals of this study were to determine differences in vibratory sensation, a proxy measure of proprioception between persons with MS and healthy controls, examine relationships between cognition and vibration sensation, and determine the contribution of cognitive function and demographics to vibratory sensation between persons with MS and healthy controls.

METHODS

One hundred and twenty-two individuals with MS, aged 20-60, with Expanded Disability Status Scale (EDSS) scores ≤5.5 and 48 healthy controls completed reaction time testing, the Stroop test and lower extremity vibratory sensation.

RESULTS

Persons with MS performed significantly worse than controls on measures of vibratory sensation (p = 0.001), two-choice reaction time (p = 0.018), and Stroop Incongruent (p < 0.001) Relative Incongruent Score (RIS) (p = 0.047). In MS, average vibration was significantly related to age (p = 0.002), sex (p = 0.038), disease severity (EDSS; p < 0.001), years since diagnosis (p = 0.016), and Stroop Word (p = 0.041). A model with demographics; including age and disease severity, two-choice reaction time, and RIS explained 33.2% of the variance vibratory sensation in persons with MS.

CONCLUSIONS

These results provide early evidence for the relation between cognitive functioning and proprioception in persons with MS and add to prior work linking cognitive functioning, postural control and falls in persons with MS. This work provides a basis for future studies combining quantitative measures of proprioception and cognitive and postural control assessment to improve fall prediction.

Participant characteristics of existing exercise studies in persons with multiple sclerosis - A systematic review identifying literature gaps

BACKGROUND

Exercise is a cornerstone in rehabilitation of persons with multiple sclerosis (pwMS), which is known to elicit beneficial effects on various symptoms and to have a potential disease-modifying effect. However, it remains to be elucidated if the existing MS exercise literature covers the full age and disability span of pwMS.

OBJECTIVE

To systematically review MS exercise studies and provide a detailed mapping of the demographic and clinical characteristics of the included pwMS.

METHODS

A systematic review of MS exercise studies were performed using MEDLINE and EMBASE. From the resulting MS exercise studies, mean sample characteristics were extracted.

RESULTS

4576 records were identified, from which 202 studies were included. Of these, 166 studies (82.2%) enrolled pwMS aged 35-54 years, 10.9% enrolled pwMS <35 years, and 6.9% enrolled pwMS ≥55 years (only 1.5% enrolled pwMS ≥60 years). A total of 118 studies (58.4%) reported Expanded Disability Status Scale (EDSS), with 88.1% of included pwMS having an EDSS between 2.0 and 6.5, while only one study enrolled pwMS with an EDSS ≥7.0. Finally, 80% of the studies included pwMS having a disease duration of 5-14.5 years.

CONCLUSION

Exercise studies in pwMS included primarily middle-aged (35-54 years) pwMS having an EDSS of 2.0-6.5 and a disease duration of 5-14.5 years. Few exercise studies were identified in young and older pwMS, in pwMS with mild disability and severe disability, and in pwMS having shorter or longer disease durations. These findings highlight the need for further investigation of exercise in these specific subgroups of pwMS as benefits of exercise might not generalize across subpopulations.

Effects of hippotherapy simulation exercise vs. conventional home exercises on muscle strength and balance in people with multiple sclerosis: A randomized controlled trial

OBJECTIVE

To determine the efficacy of hippotherapy simulation exercise on the improvement of muscle strength, balance, spasticity, and quality of life in individuals with multiple sclerosis (MS).

DESIGN

Randomized controlled trial.

SETTING

Outpatient clinic at the rehabilitation clinic of University of Usak, Turkey PARTICIPANTS: Individuals with MS (n = 40) participated in this randomized clinical study.

INTERVENTIONS

Patients in both groups received 36 treatment sessions, 3 times per week for 12 consecutive weeks. Subjects in the study group performed hippotherapy simulation exercise via a hippotherapy simulator device. The control group received conventional home exercises.

MAIN OUTCOME MEASURES

The primary outcome measures included the Monitoring My Multiple Sclerosis (MMMS) Scale, the Berg Balance Scale (BBS), and the Timed Up and Go (TUG) test; quadriceps muscle strength was measured with a dynamometer.

RESULTS

At the level of physical activity, post-intervention MMMS measures showed significant differences in both cases. TUG was significantly lower, and muscle strength and BBS were significantly higher in both post-interventions. No outcome measure showed a significant difference between the groups at both post-intervention and follow-up.

CONCLUSIONS

The results of this study in the field of hippotherapy simulation exercise for people with MS indicate a positive effect on health conditions, balance, mobility skills, and muscle strength. Further studies are necessary to confirm these preliminary results.

Core stability-based balance training and kinesio taping for balance, trunk control, fear of falling and walking capacity in patients with multiple sclerosis: A randomized single-blinded study

BACKGROUND

Trunk performance-based therapies are important in the Multiple Sclerosis (MS) rehabilitation process since they have been associated with balance, trunk performance, fall prevention, and walking capacity. Kinesio taping (KT) is a popular approach that has recently been used to treat a variety of musculoskeletal and neuromuscular impairments. Therefore, the aim of this single-blind, randomized controlled study was to investigate the effects of KT combined trunk stabilization-based balance training on balance, trunk control, walking capacity, and fear of falling in patients with MS.

MATERIAL AND METHODS

Thirty patients diagnosed with MS were randomly assigned to the KT group or the control group. The control group received core stability-based balance training and the KT group was treated with KT applied on global trunk muscles in addition to core stability-based balance training. Balance was measured with the Mini BESTest, trunk control with the Trunk Impairment Scale, fear of falling with the Falls Efficacy Scale and walking capacity with the 2-minute walk test.

RESULTS

Balance, trunk control, fear of falling, and walking capacity of all the patients improved after treatment (p < 0.05). No superiority was found between the groups in terms of treatment efficacy (p > 0.05).

CONCLUSION

In conclusion, core stability-based balance training was effective in patients with MS, and the addition of KT had no additional effect in terms of balance, trunk control, fear of falling, and walking capacity.

Effects of vibration training on motor and non-motor symptoms for patients with multiple sclerosis: A systematic review and meta-analysis

Background

Vibration therapy is one of the rehabilitation programs that may be effective in treating both motor and non-motor symptoms in Multiple Sclerosis patients. We conducted a comprehensive systematic review and meta-analysis to assess the effects of vibration therapy on motor and non-motor symptoms (functional mobility, balance, walking endurance, gait speed, fatigue, and quality of life) of this population.

Methods

A systematic search of PubMed, Embase, the Cochrane Library, Web of Science, Physiotherapy Evidence Database, Scopus, Google Search Engine, and the China National Knowledge Infrastructure (CNKI). Two reviewers independently assessed the study quality.

Results

Fourteen studies with 393 participants were finally included in the meta-analysis. The pooled results showed that vibration therapy had a significant advantage over the control intervention in improving balance function [mean difference (MD) = 2.04, 95% confidence interval (CI): 0.24-3.84, P = 0.03], and walking endurance (SMD = 0.34, 95% CI: 0.07-0.61, P = 0.01). Meanwhile, the degree of disability subgroup analysis revealed that the Expanded Disability Status Scale (EDSS) score (3.5-6) significantly improved functional mobility (MD: -1.18, 95% CI: -2.09 to 0.28, P = 0.01) and balance function (MD: 3.04, 95% CI: 0.49-5.59, P = 0.02) compared with the control group, and the EDSS (0-3.5) were more beneficial in walking endurance. The duration subgroup analysis indicated a significant difference in the effect of the duration (<4 weeks) on enhancing walking endurance (SMD: 0.46, 95% CI: 0.04-0.87, P = 0.03). However, no significant improvement was found in functional mobility, gait speed, fatigue, and quality of life.

Conclusion

Vibration therapy may improve balance function and walking endurance, and the degree of disability and duration of intervention may affect outcomes. The evidence for the effects of vibration therapy on functional mobility, gait speed, fatigue, and quality of life remains unclear. More trials with rigorous study designs and a larger sample size are necessary to provide this evidence.

Systematic Review Registration

PROSPERO, https://www.crd.york.ac.uk/prospero/#recordDetails, identifier: CRD42022326852.

Effects of Different Exercise Therapies on Balance Function and Functional Walking Ability in Multiple Sclerosis Disease Patients-A Network Meta-Analysis of Randomized Controlled Trials

The objective of this research is to assess the effects of seven different exercise therapies (aquatic exercise, aerobic exercise, yoga, Pilates, virtual reality exercise, whole-body vibration exercise, and resistance exercise) on the balance function and functional walking ability of multiple sclerosis disease patients. Materials and Methods: The effects of different exercise interventions on the balance function and functional walking ability in people with multiple sclerosis were assessed by searching five databases: PubMed, Embase, Cochrane Library, Web of Science, and CNKI; only randomized controlled trials were included. The included studies were assessed for risk of bias using the Cochrane assessment tool. Results: The RCTs were collected between the initial date of the electronic databases’ creation and May 2022. We included 31 RCTs with 904 patients. The results of the collected data analysis showed that yoga can significantly improve patients’ BBS scores (SUCRA = 79.7%) and that aquatic exercise can significantly decrease patients’ TUG scores (SUCRA = 78.8%). Conclusion: Based on the network meta-analysis, we suggest that although each type of exercise is useful, yoga, virtual reality training, and aerobic training are more effective in improving the balance function of people with MS; aquatic exercise, virtual reality training, and aerobic training are more effective in improving the functional walking ability of people with MS.

Geriatric Falls: A Registry-Based Study in the Netherlands

BACKGROUND

Falls in people 65 years and older evaluated in the emergency department are increasing. Of all unintentional injury-related deaths among older people, 55% are due to falls. The impact of falls, especially concerning Dutch older people with the highest proportion of living independently worldwide, is unclear.

OBJECTIVE

To identify the influence of age, gender, health conditions, and type of fall on the severity of injury, hospital length of stay, mortality, and discharge destination.

METHODS

A total number of 6,084 patients from a comprehensive regional trauma care system, 65 years and older and hospitalized after a fall, were included. Groups were compared for patient-related factors and multivariable logistic regression analysis to explore the consequences.

RESULTS

Mean age was 82 years (SD = 8.3), and 70% were female. Most falls (66.4%) were due to "slipping and tripping" or "falls on the same level," 57.4% had Injury Severity Scores between 9 and 12, and 43.3% were discharged home. Higher age and type of fall increased the likelihood of severe injuries. Men experienced shorter hospital stays than women and were less frequently discharged home. Mortality was higher in males (10.8%) than in females (6.7%) and increased with the American Society of Anesthesiologists scores for preexisting health conditions.

CONCLUSION

Advanced age, gender, type of fall, and prior health status play a significant role in the severity of injuries, length of hospital stay, 30-day mortality, and higher discharge destination to care homes in older people hospitalized after a fall.

Active Videogaming Interventions in Adults with Neuromuscular Conditions: A Scoping Review

This review synthesized active videogaming (AVG) intervention literature over a 10-year period (2010-2020) for people with neuromuscular conditions (18-64 years of age), examining interventions that aimed to improve health and secondary conditions, physical activity, and outcomes quality of life (QOL). Systematic searches yielded 40 eligible studies. The major groups were multiple sclerosis (40%) and stroke (33%), and the study participants had mostly mild-to-moderate disability who were able to play games in a standing position. Research designs primarily involved randomized controlled trials (65%) and pre/post-trial design without a control group (28%). The majority of interventions used commercial off-the-shelf gaming systems, such as Nintendo Wii and Microsoft Kinect. Studies reported significant improvements in health outcomes, specifically in balance (n = 30/36), mobility (n = 24/27), and cardiorespiratory fitness (n = 6/8). Positive changes were also seen in secondary conditions (n = 8/12), physical activity (n = 3/4), and QOL outcomes (n = 8/16). AVG research for people with neuromuscular conditions has grown in both quantity and quality but several gaps remain. Study findings provide a roadmap for future AVG trials on understudied populations, and highlight technology and targeted outcomes as drivers of future intervention research.

Virtual reality-based cognitive stimulation using GRYDSEN software as a means to prevent age-related cognitive-mobility disorders – a pilot observational study

The human aging process is associated with systematic deterioration of cognitive and motor performance. Age-related deficits in motor skills and symptoms of cognitive decline, such as memory, attention and executive functioning problems, are major contributors to a loss of functional independence and reduced quality of life of the elderly. The virtual reality system presented can be used as an aid for effective training of those skills. The use of virtual reality training for therapeutic purposes is promising – not only does it provide encouraging medical and psychological effects but it may also be considered as an interesting leisure activity for seniors. The paper presents a pilot study which aims to qualitatively assess the usefulness of a VR technology-based solution for training cognitive and motor functions. The pre-test phase of the study was conducted on 9 subjects aged 62-81 (M = 71.66; SD = 7.00), who were asked to evaluate the performed tasks in terms of novelty and attractiveness. All subjects completed the pilot study. The SUS result was 55.56 (SD = 9.90), which is a marginal result. However, the UEQ result showed that all aspects of the game were reported as satisfactory. The pilot studies show that VR is well tolerated by the elderly. As demonstrated by the results, the system has moderate utility, but may be a promising solution for training cognitive-motor skills.

Efficacy of Virtual Reality and Exergaming in Improving Balance in Patients With Multiple Sclerosis: A Systematic Review and Meta-Analysis

Multiple sclerosis (MS) is one of the most common causes of neurological progressive disease and can lead to loss of mobility, walk impairment, and balance disturbance. Among several rehabilitative approaches proposed, exergaming and virtual reality (VR) have been studied in the recent years. Active video game therapy could reduce the boredom of the rehabilitation process, increasing patient motivation, providing direct feedback, and enabling dual-task training. Aim of this systematic review was to assess the efficacy of exergaming and VR for balance recovery in patients with MS. PubMed, Scopus, and Web of Science were systematically searched from the inception until May 14, 2021 to identify randomized controlled trials (RCTs) presenting: patients with MS as participants, exergaming and VR as intervention, conventional rehabilitation as comparator, and balance assessment [Berg Balance Scale (BBS)] as outcome measure. We also performed a meta-analysis of the mean difference in the BBS via the random-effects method. Out of 93 records, this systematic review included and analyzed 7 RCTs, involving a total of 209 patients affected by MS, of which 97 patients performed exergaming or VR and 112 patients underwent conventional rehabilitation. The meta-analysis reported a significant overall ES of 4.25 (p < 0.0001), showing in the subgroup analysis a non-significant ES of 1.85 (p = 0.39) for the VR and a significant ES of 4.49 (p < 0.0001) for the exergames in terms of the BBS improvement. Taken together, these findings suggested that balance rehabilitation using exergames appears to be more effective than conventional rehabilitation in patients affected by MS.

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.

Effectiveness of Virtual Reality Rehabilitation in Persons with Multiple Sclerosis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Multiple Sclerosis (MS) is a chronic disease with physical, cognitive, and psychosocial impairments. Virtual Reality (VR) has been used as an innovative tool in neurological rehabilitation. There are promising new studies that have used commercial video games consoles for the rehabilitation of people with MS.

OBJECTIVES

The aim of this systematic review is to summarize the effectiveness of using VR on functional mobility, fatigue, quality of life and balance in people with MS, compared with conventional exercises or no intervention.

METHODS

Six databases (Scielo, Lilacs, Pubmed, Cochrane library, Embase and PEDro) were searched using some of following terms: "Virtual reality" AND "Multiple sclerosis" AND " randomized controlled trial". Two reviewers performed the search, selection, and extraction of data from the studies. The methodological quality of the articles was assessed using the PEDro scale and the risk of bias was independently assessed by two reviewers using the Cochrane Collaboration Risk of Bias tool. Mean differences and confidence intervals were combined and calculated in meta-analysis.

RESULTS

Nine randomized clinical trials were included, with a total sample of 424 participants. In general, functional mobility presented similar improvement between groups, while for fatigue, quality of life and balance, VR promoted improvement equal to or greater than the conventional exercises. The meta-analysis confirmed that for functional mobility, VR does not promote significant improvement, while for fatigue, quality of life and balance, VR promotes superior improvement.

CONCLUSION

This systematic review demonstrated a positive effect of using VR in people with MS in relation to fatigue, quality of life and balance, compared to the conventional exercises. For functional mobility, VR associated or not with conventional exercises does not seem to bring additional benefits. Larger and methodologically robust studies are need.

OTHER

There was no funding for this systematic review. PROSPERO Registration Number CRD42021226471.

Modern Technologies in the Rehabilitation of Patients with Multiple Sclerosis and Their Potential Application in Times of COVID-19

Background and Objectives: The COVID-19 pandemic required the adoption of new technologies to improve access to healthcare at an unprecedented speed, as social distancing became mandatory. The aim of this systematic review was to analyze the effectiveness of using new technologies in the rehabilitation of multiple sclerosis (MS) patients and discuss their potential role during the COVID-19 pandemic. Material and Methods: The studies were identified by searching two online databases-PUBMED and Web of Science. Combinations of the key words "Multiple sclerosis" and "e-health"; "Multiple sclerosis" and "virtual reality"; "Multiple sclerosis" and "telerehabilitation"; "Multiple sclerosis" and "new technologies"; "Multiple sclerosis" and "tele-exercise" were used to find suitable publications. Results: A total of 17 studies were included. Although the overall number of participants in all the studies was 904, two of the studies were conducted on the same group. Thus, a total of 854 participants were involved in the studies included. All participants were diagnosed with MS. In 10 studies, participants had to be diagnosed according to the McDonald criteria. Of the included studies: five involved intervention at participants' home, six were conducted using Xbox Kinect, and seven studies reported no adverse outcomes. Conclusion: The review proves telerehabilitation to be an effective motivational tool to restore and maintain both physical and cognitive function in patients with MS. Remote communication technologies seem to be measures of high effectiveness in rehabilitating and supporting MS patients especially during the COVID-19 pandemic, as the traditional rehabilitation option is less accessible or in some cases inaccessible for these patients.

Effect of dual-task training on balance in patients with multiple sclerosis: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effects of dual-task training on static and dynamic balance in patients with multiple sclerosis.

DATA SOURCES

PubMed/MEDLINE, EMBASE, Scopus, and PEDro databases were searched from inception to March 1, 2021.

METHODS

This study was conducted in agreement with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two reviewers assessed studies for inclusion and extracted data. We used the Physiotherapy Evidence Database scale to evaluate the methodological quality and the risk-of-bias. Randomized clinical trial data were pooled for the meta-analysis. The effect sizes and 95% confidence interval (CI) were calculated by random-effect models. Egger regression and Begg-Mazumdar rank correlation test were used for publication bias.

RESULTS

A total of 13 studies involving 584 patients (42.3 ± 9 years mean ± SD; 377 females) met the inclusion criteria for the systematic review, while nine were included in the meta-analysis. People who received dual-task training interventions showed significant improvements in the Timed Up & Go test 0.44 [(95% CI = 0.22; 0.65), P-value<0.001], and in the Berg Balance scale 0.46 [(95% CI = 0.07; 0.85), P-value = 0.02]. Low and moderate heterogeneity between the studies was found for the Timed Up & Go test and the Berg Balance scale, respectively.

CONCLUSION

The findings from the current meta-analysis support dual-task training as a beneficial therapy for improving dynamic balance and functional mobility in patients with multiple sclerosis. The limited number of studies that investigated static balance performance after dual-task training do not currently allow us to draw a conclusion about any possible improvements in this ability.