Effectiveness of virtual reality on balance ability in individuals with incomplete spinal cord injury: A systematic review

Effect of a virtual walking and exercise-based intervention on muscle strength and activation in people with incomplete spinal cord injury

This study aims to assess the effect of combining virtual walking (VW) therapy with a physical exercise (PE) program compared to PE alone on lower limb strength and muscle activation in people with incomplete spinal cord injury (iSCI). 38 participants performed 3 sessions/week during 6 weeks of Experimental Intervention (EI): VW and PE; or Control intervention (CI): Placebo-VW and PE. Strength and muscle activation of main lower limb muscles were assessed. EI group exhibited a general strength increase after intervention (T2), (16.31-34.72 N), and maintained this improvement up to 1-month-follow-up (T3) for hip abduction and extension movements. The CI group only showed improvements in hip abduction and extension movements (18.34 (7.13) N and 19.98 (9.60) N, respectively). EI group also exhibited an increase of activation in all agonistic muscles in T2 (36.02-20.24 µV), except gastrocnemius. Gastrocnemius and rectus femoris activation as antagonistic decreased during dorsal flexion (- 14.28 (5.61) µV) and hip extension (- 14.78 [6.11] µV), respectively. CI group only showed an activation increase of agonistic muscles of hip abduction and extension (22.16 (9.80) µV and 28.82 (9.14) µV, respectively), without changes in antagonistic activation. VW could enhance the PE effects regarding muscle strength and activation in people with iSCI.Registration number: NCT04809987.

Psychological outcomes of extended reality interventions in spinal cord injury rehabilitation: a systematic scoping review

STUDY DESIGN

Systematic scoping review.

OBJECTIVES

Extended reality (XR) is becoming a recognisable tool for assisting in spinal cord injury (SCI) rehabilitation. While the success of XR mediated interventions is often evaluated based on improvements in physical and functional performance, the present systematic scoping review aimed to identify and synthesize evidence on reported psychological outcomes of XR interventions in SCI rehabilitation. In doing so, we aimed to contribute towards an adaptation of XR that is meaningful for individuals living with SCI.

METHODS

Seven bibliometric databases were systematically searched. Included studies needed to be peer-reviewed, test structured and targeted XR interventions in an adult (≥ 16 years) SCI population, and assess any psychological construct. Individual double-screening against a pre-defined eligibility criteria was performed. Data from the included studies were extracted, tabulated, and analysed.

RESULTS

A total of 964 unique studies were initially identified. 13 studies were included in the analysis. The psychological outcomes most frequently quantified were depression, self-esteem, and anxiety. Among other things, qualitative evidence suggests VR-based interventions provided enjoyment, relaxation, and a source of positive distraction.

CONCLUSION

Immersive XR interventions in SCI rehabilitation have been positively evaluated, both qualitatively and quantitatively, based on the psychological outcomes of participants. While further research is needed, we find immersive XR to be an emerging treatment option with promise for maintaining and improving psychological health during SCI rehabilitation.

Effects of closed kinetic chain exercises on balance and gait in people with multiple sclerosis: A randomized controlled trial

INTRODUCTION

Balance and gait impairments are among the most common consequences of multiple sclerosis (MS). A closed kinetic chain enhances balance and gait abilities in people with multiple sclerosis (PwMS). This study aims to compare the effectiveness of an integrated Telko and conventional physical therapy (CPT) intervention versus CPT alone on gait and balance in PwMS.

METHODS

Twenty-six PwMS were enrolled in the trial, and they were randomized to either the combined Telko and CPT experimental group (n = 13) or the CPT alone control group (n = 13). All participants underwent 15-min sessions of CPT three times a week for four weeks. Additionally, participants in the experimental group received a 15-min Telko training session after each CPT session. Outcome measures consisted of the Berg Balance Scale (BBS), the 6-Minute Walk Test (6MWT), and the Timed Up and Go (TUG) assessment.

RESULTS

Twenty-four PwMS completed the study. The PwMS in the combined Telko and CPT experimental group exhibited significant improvements in balance, functional capacity, gait speed, and mobility following the intervention (P < 0.05). In the CPT group, PwMS also experienced significant improvements in functional capacity (P < 0.05). The between-group analysis revealed no significant differences among the outcome measures (P > 0.05).

CONCLUSIONS

The combined Telko and CPT intervention did not demonstrate superiority over CPT alone in improving balance and gait in PwMS. Further experimental studies are necessary to fully understand the effects of a closed kinetic chain for lower extremities on the balance and gait of individuals with PwMS.

Effectiveness of virtual-walking intervention combined with exercise on improving pain and function in incomplete spinal cord injury: a feasibility study

STUDY DESIGN

A feasibility pilot study.

OBJECTIVE

To assess the feasibility a full-scale Randomized Controlled Trial aimed at assessing the beneficial effect of a Virtual Walking (VW)-based (Experimental intervention (EI)) on neuropathic pain and functionality in people with incomplete spinal cord injury (SCI).

SETTING

A hospital service (Hospital Universitario y Politécnico La Fe) and disability associations (TetraSport, CODIFIVA and ASPAYM).

METHODS

Twelve people with chronic incomplete SCI were randomized to EI (VW plus therapeutic exercise program (TE)) -or Control Intervention (CI (placebo VW and TE)) groups. A six-week intervention (3 sessions/week) was carried out. To assess feasibility, the following outcomes were used: level of restriction and validity of inclusion and exclusion criteria, participants' compliance, accessibility and acceptability of the intervention for participants, adequate pre-training time of physiotherapists. To explore therapy effectiveness, pain severity, and interference, mean and maximum isometric strength, walking speed, and walking ability were assessed before (Time 1, T1) and after (Time 2, T2) the intervention.

RESULTS

20% of the participants initially recruited did not meet inclusion criteria. In addition, all participants completed at least 80% of the intervention sessions and none of the participants dropped out before T2. No serious adverse event was found. Moreover, 91.67% of participants were willing to perform the intervention again and all therapists involved were adequately pre-trained. Finally, our preliminary results suggest that the proposed EI is effective.

CONCLUSION

A full-scale RCT is feasible and preliminary results suggest that VW with TE could have a beneficial impact on pain and functionality in this population.

Combined noninvasive brain stimulation virtual reality for upper limb rehabilitation poststroke: A systematic review of randomized controlled trials

Upper limb impairments are common consequences of stroke. Noninvasive brain stimulation (NIBS) and virtual reality (VR) play crucial roles in improving upper limb function poststroke. This review aims to evaluate the effects of combined NIBS and VR interventions on upper limb function post-stroke and to provide recommendations for future studies in the rehabilitation field. PubMed, MEDLINE, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched from inception to November 2023. Randomized controlled trials (RCTs) encompassed patients with a confirmed stroke diagnosis, administrated combined NIBS and VR compared with passive (i.e., rest) or active (conventional therapy), and included at least one outcome assessing upper limb function (i.e., strength, spasticity, function) were selected. The quality of the included studies was assessed using the Cochrane Collaboration tool. Seven studies met the eligibility criteria. In total, 303 stroke survivors (Mean age: 61.74 years) were included in this review. According to the Cochrane Collaboration tool, five studies were classified as "high quality," while two were categorized as "moderate quality". There are mixed findings for the effects of combined NIBS and VR on upper limb function in stroke survivors. The evidence for the effects of combined transcranial direct current stimulation and VR on upper limb function post-stroke is promising. However, the evidence regarding the effects of combined repetitive transcranial magnetic stimulation and VR on upper limb function is limited. Further randomized controlled trials with long-term follow-up are strongly warranted.

Effectiveness of immersive virtual reality training to improve sitting balance control among individuals with acute and sub-acute paraplegia: A randomized clinical trial

OBJECTIVES

Spinal cord injury (SCI) is a disabling condition with physical, psychological, and financial consequences. The study's goal is to compare the effectiveness of immersive virtual reality (VR) training in balance among individuals with incomplete paraplegia to that of functional electrical stimulation (FES).

DESIGN

Two groups, randomized clinical trial.

SETTING

Neurological Physiotherapy Out Patient Department, Tertiary Care Hospital.

PARTICIPANTS

Eighteen people aged 18-60 years with incomplete SCI.

INTERVENTIONS

VR training along with conventional physical therapy (CPT) and FES for Rectus Abdominis and Erector Spinae with CPT five times a week for 4 weeks.

OUTCOME MEASURES

The outcome measures were Modified Functional Reach Test (mFRT) and Function in Sitting Test (FIST) to assess sitting balance and Spinal Cord Independence Measure III (SCIM III) for the level of independence. Assessments were taken before initiating treatment and at the end of the 2 and 4 weeks after treatment. Within-group analyses for the mFRT values were performed using Repeated Measures ANOVA test, and between-group analyses were performed using the independent t-test test. Friedman and Mann-Whitney U-tests were used for analyzing FIST and SCIM III.

RESULTS

All variables (mFRT and FIST) improved significantly in both groups (P < 0.05), with the VR + CPT group showing a more significant result than the FES + CPT group (P value < 0.05), except for SCIM III.

CONCLUSION

VR as an adjunct to CPT demonstrated proved to be an effective treatment to improve balance among individuals with incomplete paraplegia.Trial registration: Clinical Trials Registry India identifier: CTRI/2020/03/024080.

Interventions to Improve Standing Balance in Individuals With Incomplete Spinal Cord Injury: A Systematic Review and Meta-Analysis

Background

Incomplete spinal cord injury (iSCI) often results in impaired balance leading to functional impairments. Recovery of standing balance ability is an important aim of rehabilitative programs. However, limited information is available on effective balance training protocols for individuals with iSCI.

Objectives

To assess the methodological quality and effectiveness of various rehabilitation interventions for improving standing balance in individuals with iSCI.

Methods

A systematic search was performed in SCOPUS, PEDro, PubMed, and Web of Science from inception until March 2021. Two independent reviewers screened articles for inclusion, extracted data, and evaluated methodological quality of the trials. PEDro Scale was used to assess the quality of randomized controlled trials (RCT) and crossover studies while pre-post trials were assessed using the modified Downs and Black tool. A meta-analysis was performed to quantitatively describe the results. The random effects model was applied to present the pooled effect.

Results

Ten RCTs with a total of 222 participants and 15 pre-post trials with 967 participants were analyzed. The mean PEDro score and modified Downs and Black score was 7/10 and 6/9, respectively. The pooled standardized mean difference (SMD) for controlled and uncontrolled trials of body weight-supported training (BWST) interventions was -0.26 (95% CI, -0.70 to 0.18; p = .25) and 0.46 (95% CI, 0.33 to 0.59; p < .001), respectively. The pooled effect size of -0.98 (95% CI, -1.93 to -0.03; p = .04) indicated significant improvements in balance after a combination of BWST and stimulation. Pre-post studies analyzing the effect of virtual reality (VR) training interventions on Berg Balance Scale (BBS) scores in individuals with iSCI reported a mean difference (MD) of 4.22 (95% CI, 1.78 to 6.66; p = .0007). Small effect sizes were seen in pre-post studies of VR+stimulation and aerobic exercise training interventions indicating no significant improvements after training on standing balance measures.

Conclusion

This study demonstrated weak evidence to support the use of BWST interventions for overground training for balance rehabilitation in individuals with iSCI. A combination of BWST with stimulation however showed promising results. There is a need for further RCTs in this field to generalize findings. Virtual reality-based balance training has shown significant improvement in standing balance post iSCI. However, these results are based on single group pre-post trials and lack appropriately powered RCTs involving a larger sample size to support this intervention. Given the importance of balance control underpinning all aspects of daily activities, there is a need for further well-designed and appropriately powered RCTs to evaluate specific features of training interventions to improve standing balance function in iSCI.

A Novel Neurorehabilitation Approach for Neural Plasticity Overstimulation and Reorganization in Patients with Neurological Disorders

Neurological disorders are those that are associated with impairments in the nervous system. These impairments affect the patient’s activities of daily living. Recently, many advanced modalities have been used in the rehabilitation field to treat various neurological impairments. However, many of these modalities are available only in clinics, and some are expensive. Most patients with neurological disorders have difficulty reaching clinics. This review was designed to establish a new neurorehabilitation approach based on the scientific way to improve patients’ functional recovery following neurological disorders in clinics or at home. The human brain is a network, an intricate, integrated system that coordinates operations among billions of units. In fact, grey matter contains most of the neuronal cell bodies. It includes the brain and the spinal cord areas involved in muscle control, sensory perception, memory, emotions, decision-making, and self-control. Consequently, patients’ functional ability results from complex interactions among various brain and spinal cord areas and neuromuscular systems. While white matter fibers connect numerous brain areas, stimulating or improving non-motor symptoms, such as motivation, cognitive, and sensory symptoms besides motor symptoms may enhance functional recovery in patients with neurological disorders. The basic principles of the current treatment approach are established based on brain connectivity. Using motor, sensory, motivation, and cognitive (MSMC) interventions during rehabilitation may promote neural plasticity and maximize functional recovery in patients with neurological disorders. Experimental studies are strongly needed to verify our theories and hypothesis.

Proprioceptive Focal Stimulation (Equistasi®) for gait and postural balance rehabilitation in patients with Parkinson's disease: A systematic review

Gait and postural deficits are the most common impairments in patients with Parkinson's Disease (PD). These impairments often reduce patients' quality of life. Equistasi^® is a wearable proprioceptive stabilizer that converts body thermic energy into mechanical vibration. No systematic reviews have been published investigating the influences of Equistasi^® on gait and postural control in patients with PD. This review aimed to examine the effects of proprioceptive focal stimulation (Equistasi^®) on gait deficits and postural instability in patients with PD. PubMed, Scopus, PEDro, REHABDATA, web of science, CHAINAL, EMBASE, and MEDLINE were searched from inception to July 2021. The methodological quality of the selected studies was evaluated using the Physiotherapy Evidence Database (PEDro) scale. Five studies met the eligibility criteria. The scores on the PEDro scale ranged from 3 to 8, with a median score of 8. The results showed evidence for the benefits of the proprioceptive focal stimulation (Equistasi^®) on gait and postural stability in individuals with PD. Proprioceptive focal stimulation (Equistasi^®) appears to be safe and well-tolerated in patients with PD. Proprioceptive focal stimulation (Equistasi^®) may improve gait ability and postural stability in patients with PD. Further high-quality studies with long-term follow-ups are strongly needed to clarify the long-term effects of proprioceptive focal stimulation (Equistasi^®) in patients with PD.

Effect of virtual reality training on standing balance in individuals with incomplete spinal cord injury

Recovery of balance ability during standing is one of the primary and essential aims of rehabilitative programs in individuals with incomplete spinal cord injury (iSCI). A sample of ten participants (mean age: 35.7 years, range: 25-63 years) with traumatic or non-traumatic iSCI (AIS grade C or D) and were able to stand with or without the support of an assistive device for a minimum of 2 min were recruited from the rehabilitation department of the Indian Spinal Injuries Centre, New Delhi, India. The participants received Virtual Reality (VR) based balance training for one hour, three times a week for four weeks on the Nintendo Wii gaming console. Participants were assessed three times: pre-intervention, post-intervention and follow-up assessment for the total ellipse area (TEA), total sway perimeter (TSP), sway range (anterior-posterior/medio-lateral (AP/ML)) and limits of stability (LOS). At post-intervention assessment, significant increases in comparison with pre-intervention scores was found in LOS (P=0.00), TEA with eyes open (EO) (P=0.00) and eyes closed (EC) (P=0.00), TSP with EO (P=0.00) and EC (P=0.00), sway range in AP direction (SD-AP) with EO (P=0.01) and EC (P=0.02) and sway range in ML direction (SD-ML) with EO (P=0.02) and EC (P=0.01). At follow-up assessment, a significant improvement in comparison to post intervention scores was found in TEA measured both in EO (P=0.01) and EC conditions (P=0.02), TSP measured with EO (P=0.01) and SD-ML both with EO (P=0.04) and EC (P=0.01). No significant changes were found in LOS (P=0.89), TSP measured with EC (P=0.38) and SD-AP both with EO (P=0.50) and EC (P=1). However, significant improvement was seen on comparing follow-up assessment scores with pre-intervention scores for all variables, such as LOS (P=0.00), TEA in EO (P=0.00) and EC (P=0.00), TSP with EO (P=0.00) and EC (P=0.00), SD-AP with EO (P=0.01) and EC (P=0.02) and SD-ML with EO (P=0.01) and EC (P=0.00). VR-based balance training intervention was able to elicit improvements in balance ability and maintain it during follow-up despite a small training dosage suggesting that it is a promising intervention for standing balance rehabilitation among individuals with iSCI. The VR-based balance training challenges elements of balance, which physical therapists may want to consider when designing a comprehensive rehabilitation program.

Clinical Trials Registry-India: CTRI/2018/12/016814.

Rehabilitation interventions for cognitive deficits in stroke survivors: A systematic review of randomized controlled trials

Cognitive deficits are one of the most common impairments after stroke. It negatively affects physical and social functioning. Rehabilitation interventions for cognitive deficits post-stroke have taken less consideration. The present study aimed to provide an overview of the effects of various rehabilitation interventions on cognitive functions in patients with stroke. PUBMED, SCOPUS, PEDro, EMBASE, MEDLINE, and REHABDATA were searched for randomized controlled trials (RCTs) investigating the effects of rehabilitation interventions on cognitive domains poststroke until August 2021. The methodological quality of the selected studies was evaluated using the Cochrane Collaboration tool, and the effect sizes were calculated. Forty-four studies met the inclusion criteria. A total of 3561 individuals with stroke, 57.60% of whom were males. The mean age for all participants was 65.48 years. Eighteen RCTs were high, moderate (n = 17), and low methodological quality (n = 9). The results showed evidence for the beneficial effects of many rehabilitation interventions on cognition in individuals with stroke. Rehabilitation plays a crucial role in improving cognitive functions in stroke patients with mild cognitive deficits. Virtual reality (VR), computer-based cognitive rehabilitation (CBCR), and non-aerobic exercises may promote cognitive functions in patients with stroke.

Virtual reality for balance and mobility rehabilitation following traumatic brain injury: A systematic review of randomized controlled trials

BACKGROUND

Balance and mobility deficits are most prevalent impairments in patients with traumatic brain injury (TBI). The evidence has proposed that rehabilitation plays an important role in improving balance and mobility post-TBI. Virtual reality (VR) is a computer technology that provides immersed users to generate feedback such as visual, audio, and haptic.

OBJECTIVE

This review aimed to examine the effects of the VR treatment intervention on balance and mobility in patients with TBI and to define the most effective VR treatment protocol.

METHODS

SCOPUS, PEDro, PubMed, REHABDATA, EMBASE, and the web of science were searched for experimental trials examining the impacts of VR training on balance and mobility in patients with TBI from inception until July 2022. Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the selected studies.

RESULTS

Five randomized controlled trials (RCTs) met the inclusion criteria. The PEDro scores ranged from 6 to 8, with a median of 6. A total of 157 patients with TBI were included in this review, 31.2% of whom were females. The findings showed that VR intervention is not superior to traditional physiotherapy interventions in improving balance and mobility post- TBI.

CONCLUSIONS

The preliminary findings showed that the influence of VR on the balance and mobility ability in patients with TBI is promising. Combining VR with other concurrent rehabilitation interventions may show more significant improvements in balance and mobility compared to VR interventions alone. The optimal VR treatment protocol remains unclear. Further randomized controlled trials are strongly needed.

Clinical effectiveness of focal muscle vibration on gait and postural stability in individuals with neurological disorders: A systematic review

BACKGROUND

Gait deficits and postural instability are common impairments among patients with neurological disorders. These impairments limit function independence and decrease activities of daily living. Focal muscle vibration (FMV) produces vibration signals affecting the nervous system. No systematic review has been published examining the influence of FMV on gait ability and postural stability in individuals with neurological disorders.

OBJECTIVES

This study aimed to investigate the effects of FMV on gait and postural stability parameters in individuals with neurological disorders.

METHODS

PubMed, Scopus, PEDro, REHABDATA, web of science, CHAINAL, EMBASE, and MEDLINE were searched from inception to July 2021. The methodological quality of the selected studies was evaluated using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Five randomized controlled trials (RCTs) met the eligibility criteria. The scores on the PEDro scale ranged from seven to nine, with a median score of eight. The results showed evidence for the benefits and non-benefits of the FMV intervention on gait and postural stability in individuals with neurological disorders.

CONCLUSIONS

The FMV intervention is safe and well-tolerated in individuals with neurological disorders. The evidence for the effects of FMV on individuals with neurological disorders was limited. Further high-quality studies with long-term follow-up are strongly needed.

The effects of virtual soccer game on balance, gait function, and kick speed in chronic incomplete spinal cord injury: a randomized controlled trial

STUDY DESIGN

Participant-blinded comparative pre-post randomized controlled trial.

OBJECTIVE

To evaluate the effects of virtual soccer game on balance, gait function, and kick speed in individuals with spinal cord injuries.

SETTING

Forty participants with incomplete spinal cord injury (SCI) were included.

METHODS

The participants were randomized into either an experimental group (EG) or a control group for treatment 3 days/week over 4 weeks. The clinical outcomes included the results of the chair stand test (CST), timed up-and-go (TUG) test, and 10 m walking test (10MWT). The virtual reality (VR) content outcome measure was kick speed.

RESULTS

The independent t-test results indicated that the participants in the EG exhibited superior performances in the CST, TUG test, 10MWT, and kick speed test (all P < 0.05).

CONCLUSIONS

Our results provide novel, promising clinical evidence that VR rehabilitation improves both dynamic and static balance and reduces the risk of falls in patients with incomplete SCI of Asia impairment scale grades C-D.

Robot-assisted gait training in individuals with spinal cord injury: A systematic review for the clinical effectiveness of Lokomat

BACKGROUND

Spinal cord injury (SCI) is a critical medical condition that causes numerous impairments leading to accompanying disability. Robotic-assisted gait training (RAGT) offers many advantages, including the capability to increase the intensity and total duration of training while maintaining a physiological gait pattern. The effects of the RAGT 'Lokomat' on various impairments following SCI remain unclear.

OBJECTIVES

This review was conducted to examine the impacts of the RAGT 'Lokomat' on the impairments following SCI.

METHODS

We searched PubMed, SCOPUS, PEDro, REHABDATA, MEDLINE, EMBASE, and web of science from inception to January 2021. Experimental studies examining the effects of the Lokomat on the impairments following incomplete SCI were selected. The methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Sixteen studies were met the inclusion criteria. Thirteen were randomized controlled trials, two were clinical trials, and one was a pilot study. The scores on the PEDro scale ranged from two to eight, with a median score of six. The results showed evidence for the beneficial effects of the Lokomat on many motor impairments following incomplete SCI.

CONCLUSIONS

The Lokomat may improve gait speed, walking distance, strength, range of motion, and mobility after incomplete SCI. There is insufficient evidence for the effect of the Lokomat on balance, depression, cardiorespiratory fitness, and quality of life. The effects of the Lokomat on the lower extremity spasticity were limited.