Nintendo Wii rehabilitation ("Wii-hab") provides benefits in Parkinson's disease

Motivational Modulation Enhances Movement Performance in Parkinson's Disease: A Systematic Review

Background

The assessment of motivation and its modulation during treatment are essential aspects of physical therapy practice. However, the modulation of motivation has been sparsely investigated in persons with Parkinson's disease (PD) and at present no studies have synthesized its effects on movement performance.

Objectives

4The purpose of this study was to systematically examine the efficacy of motivational modulation on movement performance in PD and to provide recommendations for its role in physical therapy practice.

Methods

Systematic identification of published literature was performed adhering to PRISMA guidelines, from January 2005 to March 2023. Keywords were used in the following electronic databases: PubMed, Academic Search Complete, the Cochrane Database, Google Scholar, and the Physiotherapy Evidence Database (PEDro). A level of evidence rating was completed according to the scale provided by the American Academy of Cerebral Palsy and Development Medicine. Quality assessments were performed using the Modified Downs and Black checklist.

Results

Eight studies were included in this review, all achieving level III evidence. The methodological quality of studies was varied, with most studies attaining a fair rating. Persons with PD performed upper extremity movement tasks with greater intensity when incentivized with larger rewards compared to smaller incentives. Dopamine replacement medication, Deep Brain Stimulation, and a history of depression, had mediating effects on the response to motivational modulation.

Conclusions

Our findings suggest that it is plausible to improve adherence to exercise when physical therapists modulate motivation through computerized game achievements, gamification of tasks, or other forms of reward and non-rewarding stimuli.

The effects of exergames on upper extremity performance, trunk mobility, gait, balance, and cognition in Parkinson's disease: a randomized controlled study

BACKGROUND

In recent years, game-based exercises have been included more in the rehabilitation programs of Parkinson's disease (PD) patients and positive effects have been observed.

AIM

This study aims to investigate the effects of innovative games particularly designed for neurological patients on upper extremity performance, trunk mobility and cognition in patients with PD.

METHOD

Twenty-three patients were enrolled in this randomized controlled study and randomly allocated into two groups: Exergames Program (EP) and Conventional Exercise Program (CP). Both groups received supervised physiotherapy sessions for 3 days a week and 8 weeks in total (24 sessions). Each session lasted 1 h. Evaluations were applied before and after the treatment: 9-Hole Peg Test (9-HPT), Minnesota Manual Dexterity Test (MMDT), Trunk Impairment Scale (TIS), Montreal Cognitive Assessment (MoCA), Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Timed Up and Go (TUG), Functional Reach Test (FRT), and Parkinson Disease Questionnaire (PDQ-39).

RESULTS

Twenty patients were included in the analysis because of the dropouts. Our findings showed that both groups improved significantly in 9-HPT dominant side, MMDT, TIS, MDS-UPDRS, TUG, FRT, and PDQ-39 (p < 0.05). MoCA scores of EP group improved significantly (p < 0.05) while CP group's did not (p > 0.05). It was found that EP group had better improvements in 9-HPT dominant side, MMDT turning test, and MoCA than CP group when the differences in the changes within the groups were compared (p < 0.05).

CONCLUSION

Game-based training can be a useful rehabilitation tool to improve upper extremities performance, trunk mobility, cognition, functional mobility, balance, and quality of life and may have superiority over conventional exercises in improving cognition and upper extremity functions.

CLINICAL TRIAL NUMBER

NCT05235880. Release Date: April 1, 2022.

Effects of virtual reality versus motor imagery versus routine physical therapy in patients with parkinson's disease: a randomized controlled trial

BACKGROUND

Parkinson's Disease (PD) is the second most common progressive neurodegenerative disorder, mostly affecting balance and motor function caused mainly by a lack of dopamine in the brain. The use of virtual reality (VR) and motor imagery (MI) is emerging as an effective method of rehabilitation for people with Parkinson's disease. Motor imagery and virtual reality have not been compared in patients with Parkinson's disease. This randomized clinical trial is unique to compare the effects of virtual reality with routine physical therapy, motor imagery with routine physical therapy, and routine physical therapy alone on balance, motor function, and activities of daily living in patients with Parkinson's disease.

METHODS

A total of sixty patients with Parkinson's disease were randomized into three groups using lottery method; twenty with virtual reality therapy in addition to physical therapy (group A = VR + RPT), twenty with imagery therapy in addition to physical therapy (group B = MI + RPT), and twenty were treated with only routine physical therapy (group C = RPT). All patients were evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS) for motor function and activities of daily living, the Berg balance scale (BBS) for balance, and the Activities-specific Balance Confidence Scale (ABCs) for balance confidence at baseline, six and twelve weeks, and one month after treatment discontinuation. The one-way ANOVA was used to compare the outcomes between three groups, and the repeated measures ANOVA was used to compare the outcomes within each of the three groups at a significance level of p-value = 0.05.

RESULTS

According to UPDRS III, the VR + RPT group showed significant improvement in motor function, compared to the MI + RPT and RPT groups, as the Mean ± SD at baseline was 33.95 ± 3.501 and at the 12-week assessment was 17.20 ± 9.451 with a p-value = 0.001. In the VR + RPT group, the BBS score at baseline was 37.15 ± 3.437 and at 12th week was 50.10 ± 4.897 with a p-value = 0.019. Among the VR + RPT group, the ABCS score showed significant improvement as the M ± SD at baseline was 57.95 ± 4.629, and at the 12th week was 78.59 ± 6.386 with a p-value = 0.010. At baseline, the UPDRS II for activities of daily living in the VR + RPT group was 25.20 ± 3.036 and at 12th week it was 15.30 ± 2.364 with p-value of 0.000.

CONCLUSION

The current study found that the combination of VR and RPT proved to be the most effective treatment method for improving balance, motor function, and activities of daily living in patients with Parkinson's disease when compared to MI + RPT or RPT alone.

Der Einfluss vom Exergaming mit kommerziell verfügbaren Spielkonsolen auf die Balance und Lebensqualität bei Menschen mit idiopathischem Parkinson-Syndrom – Eine systematische Übersichtsarbeit

Hintergrund Exergaming könnte als Kombination aus Spielspaß und Training ein effektiver Therapie-Ansatz bei Gleichgewichtsstörungen und verminderte Lebensqualität (QoL) bei Parkinson-Patient*innen sein. Zugängliche Arten von Exergaming mit kommerziellen Spielkonsolen wurden bisher nicht umfassend untersucht.

Ziel Untersuchung der Fragestellung, ob Exergaming mit kommerziell verfügbaren Spielkonsolen die Balance und QoL von Patient*innen mit Morbus Parkinson verbessert.

Methode Es erfolgte eine systematische Literaturrecherche in den Datenbanken MEDLINE, Cochrance Library, EMBASE, CINHAL und PEDro. Berücksichtigt wurden Studien, die Patient*innen mit Morbus Parkinson mit kommerziell verfügbaren Exergaming-Konsolen behandelten. Als Messinstrument für Balance wurden „Berg Balance Scale“ (BBS) und „Dynamic Gait Index“ (DGI) festgelegt. Die QoL wurde mittels „Parkinsonʼs Disease Questionnaire“ (PDQ-39) evaluiert. Das Verzerrungsrisikos wurde mithilfe der PEDro-Skala und MINORS eingeschätzt. Die Studienergebnisse wurden tabellarisch zusammengefasst und ausführlich gegenübergestellt.

Ergebnisse Es wurden insgesamt 6 randomisierte kontrollierte Studien sowie 6 Kohortenstudien eingeschlossen. Die Studien umfassten insgesamt 413 Proband*innen, wovon 205 die Exergaming-Intervention erhielten. Die Analyse dieser Studien bestätigte einen positiven Effekt von Exergaming mit kommerziellen Spielkonsolen auf die Balance (BBS, DGI) und QoL (PDQ-39) bei Patient*innen mit Morbus Parkinson im ersten bis dritten Hoehn-und-Yahr-Stadium (H&Y-Stadium).

Schlussfolgerung Exergaming mit kommerziell verfügbaren Spielkonsolen kann zur Verbesserung der Balance und QoL bei Patient*innen mit Morbus Parkinson im H&Y-Stadium 1–3 verwendet werden. Für die Untersuchung des Heim-Exergaming werden weitere Studien benötigt.

Development of a Smartphone-Based mHealth Platform for Telerehabilitation

Telerehabilitation is becoming increasingly valuable as a method for expanding medical services. The smartphone-based mHealth platform (SMPT) has been developed to provide high-quality remote rehabilitation through a smartphone and inertial measurement units. The SMPT uses smartphone as a main platform with connection to medical backend server to provide telerehabilitation. Patients would be referred to therapists to receive a tutorial of exercise technique prior to conducting their home exercise. Once patients begin their home exercises, they can report any problems instantly through the SMPT. The medical staff can adjust the exercise program according to patient feedback and the data collected by the SMPT. After completing the exercise program, patients visit their clinician for re-evaluation. A Service User Technology Acceptability Questionnaire from both medical professional and public perspective revealed a high level of agreement on enhanced care, increased accessibility, and satisfaction and a moderate level of agreement on the use of this platform as a substitute for traditional rehabilitation. Concerns about privacy and discomfort were low in the medical professional and public groups. Concerns about care personnel were also significantly different between the two groups. The SMPT is a promising system for providing telerehabilitation as an adjunct to traditional rehabilitation, which may result in improved outcomes compared with those achieved when using traditional rehabilitation alone.

Occupational Therapy Practice Guidelines for People With Parkinson's Disease

IMPORTANCE

Occupational therapy practitioners address the occupational performance and participation needs of people with Parkinson's disease (PD) and their care partners.

OBJECTIVE

This Practice Guideline is informed by systematic reviews on the use of occupational therapy interventions to promote participation in occupations for people with PD and to facilitate their caregivers' participation in the caregiver role. This guideline is meant to support practitioners' clinical decision making when working with people with PD and their care partners.

METHOD

We examined and synthesized the results of four systematic reviews and integrated those results into clinical recommendations for practice.

RESULTS

Thirty-three articles from the systematic reviews served as the basis for the clinical recommendations in this Practice Guideline. Clinical recommendations are provided for interventions that have strong or moderate supporting evidence.

CONCLUSION AND RECOMMENDATIONS

Multidisciplinary, tailored, goal-oriented intervention is recommended for people with PD. Various forms of exercise can be used to improve activities of daily living and instrumental activities of daily living performance and social participation, and interventions should incorporate health behavior change techniques to support adequate physical activity levels in daily life. Mindfulness meditation and exercise can be used to support sleep, and task-oriented training can be used to improve performance of specific tasks. Occupational therapy practitioners should incorporate self-management, coaching, compensatory, cognitive-behavioral, and other approaches into multicomponent treatment plans depending on the client's needs and goals. Additional potentially appropriate intervention approaches or areas to address are discussed on the basis of existing or emerging evidence and expert opinion. What This Article Adds: This Practice Guideline provides a summary and applications of the current evidence supporting occupational therapy intervention for people with PD. It includes case examples and suggested decision-making algorithms to support practitioners in addressing client goals.

Combined effects of virtual reality techniques and motor imagery on balance, motor function and activities of daily living in patients with Parkinson's disease: a randomized controlled trial

Background

Parkinson's disease (PD) is the second most prevalent neurodegenerative disorder, impairing balance and motor function. Virtual reality (VR) and motor imagery (MI) are emerging techniques for rehabilitating people with PD. VR and MI combination have not been studied in PD patients. This study was conducted to investigate the combined effects of VR and MI techniques on the balance, motor function, and activities of daily living (ADLs) of patients with PD.

Methods

This study was a single-centered, two-armed, parallel-designed randomized controlled trial. A total of 44 patients of either gender who had idiopathic PD were randomly allocated into two groups using lottery methods. Both groups received Physical therapy (PT) treatment, while the experimental group (N: 20) received VR and MI in addition to PT. Both groups received assigned treatment for three days a week on alternate days for 12 weeks. The Unified Parkinson’s Disease Rating Scale (UPDRS) (parts II and III), Berg Balance Scale (BBS), and Activities-specific Balance Confidence (ABC) Scale were used as outcome measures for motor function, balance, and ADLs. The baseline, 6^th, and 12^th weeks of treatment were assessed, with a 16^th week follow-up to measure retention. The data was analysed using SPSS 24.

Results

The experimental group showed significant improvement in motor function than the control group on the UPDRS part III, with 32.45±3.98 vs. 31.86±4.62 before and 15.05±7.16 vs. 25.52±7.36 at 12-weeks, and a p-value < 0.001. At 12 weeks, the experimental group's BBS scores improved from 38.95±3.23 to 51.36±2.83, with p-value < 0.001. At 12 weeks, the experimental group's balance confidence improved considerably, from 59.26±5.87to 81.01±6.14, with a p-value of < 0.001. The experimental group's ADL scores improved as well, going from 22.00±4.64 to 13.07±4.005 after 12 weeks, with a p-value of < 0.001.

Conclusion

VR with MI techniques in addition to routine PT significantly improved motor function, balance, and ADLs in PD patients compared to PT alone.

Trial registration

IRCT20200221046567N1. Date of registration: 01/04/2020

A Randomized Controlled Trial of Motor Imagery Combined with Virtual Reality Techniques in Patients with Parkinson's Disease

Background: Parkinson’s disease is the second most common neurological disease, affecting balance, motor function, and activities of daily living. Virtual reality and motor imagery are two emerging approaches for the rehabilitation of patients with Parkinson’s disease. This study aimed to determine the combined effects of virtual reality and motor imagery techniques with routine physical therapy on the motor function components of individuals with Parkinson’s disease. Methods: The study was a prospective, two-arm, parallel-design randomized controlled trial. Forty-four patients with idiopathic Parkinson’s disease were randomly assigned to one of two groups. Virtual reality and motor imagery were given together with physical therapy in the experimental group (N: 20), while physical therapy treatment alone was given in the control group (N: 21). Both groups received allocated treatment for 12 weeks, 3 days a week, on alternate days. Motor function was assessed at baseline, six weeks, twelve weeks, and sixteen weeks after discontinuing treatment with the Unified Parkinson’s Disease Rating Scale part III. SPSS 24 was used to analyze the data. Results: Study results indicate that the experimental group showed significant improvements in the motor function components: tremor at rest at the 6th week (p = 0.028), 12th week (p = 0.05), and 16th week (p = 0.001), rigidity at the 6th week (p = 0.03), 12th week (p = 0.000), and 16th week (p = 0.001), posture at the 12th week (p = 0.005) and 16th week (p = 0.004), and gait at the 6th week with a p-value of (p = 0.034). Conclusions: This study demonstrated that virtual reality and motor imagery training in combination with routine physical therapy can significantly improve resting tremors, rigidity, posture, gait, and body bradykinesia in individuals with PD in comparison to patients receiving only routine physical therapy.

Effect of the Nintendo Ring Fit Adventure Exergame on Running Completion Time and Psychological Factors among University Students Engaging in Distance Learning during the COVID-19 Pandemic: A Randomized Prospective Study (Preprint)

Background

The COVID-19 outbreak has not only changed the lifestyles of people globally but has also resulted in other challenges, such as the requirement of self-isolation and distance learning. Moreover, people are unable to venture out to exercise, leading to reduced movement, and therefore, the demand for exercise at home has increased.

Objective

We intended to investigate the relationships between a Nintendo Ring Fit Adventure (RFA) intervention and improvements in running time, cardiac force index (CFI), sleep quality (Chinese version of the Pittsburgh Sleep Quality Index score), and mood disorders (5-item Brief Symptom Rating Scale score).

Methods

This was a randomized prospective study and included 80 students who were required to complete a 1600-meter outdoor run before and after the intervention, the completion times of which were recorded in seconds. They were also required to fill out a lifestyle questionnaire. During the study, 40 participants (16 males and 24 females, with an average age of 23.75 years) were assigned to the RFA group and were required to exercise for 30 minutes 3 times per week (in the adventure mode) over 4 weeks. The exercise intensity was set according to the instructions given by the virtual coach during the first game. The remaining 40 participants (30 males and 10 females, with an average age of 22.65 years) were assigned to the control group and maintained their regular habits during the study period.

Results

The study was completed by 80 participants aged 20 to 36 years (mean 23.20, SD 2.96 years). The results showed that the running time in the RFA group was significantly reduced. After 4 weeks of physical training, it took females in the RFA group 19.79 seconds (P=.03) and males 22.56 seconds (P=.03) less than the baseline to complete the 1600-meter run. In contrast, there were no significant differences in the performance of the control group in the run before and after the fourth week of intervention. In terms of mood disorders, the average score of the RFA group increased from 1.81 to 3.31 for males (difference=1.50, P=.04) and from 3.17 to 4.54 for females (difference=1.38, P=.06). In addition, no significant differences between the RFA and control groups were observed for the CFI peak acceleration (CFIPA)_walk, CFIPA_run, or sleep quality.

Conclusions

RFA could either maintain or improve an individual’s physical fitness, thereby providing a good solution for people involved in distance learning or those who have not exercised for an extended period.

Trial Registration

ClinicalTrials.gov NCT05227040; https://clinicaltrials.gov/ct2/show/NCT05227040

Applying Game-Based Approaches for Physical Rehabilitation of Poststroke Patients: A Systematic Review

Objective

A large number of patients need critical physical rehabilitation after the stroke. This study aimed to review and report the result of published studies, in which newly emerged games were employed for physical rehabilitating in poststroke patients.

Materials and Methods

This systematic review study was performed based on the PRISMA method. A comprehensive search of PubMed, Scopus, IEEE Xplore Digital Library, and ISI Web of Science was conducted from January 1, 2014, to November 9, 2020, to identify related articles. Studies have been entered in this review based on inclusion and exclusion criteria, in which new games have been used for physical rehabilitation.

Results

Of the 1326 retrieved studies, 60 of them met our inclusion criteria. Virtual reality-oriented games were the most popular type of physical rehabilitation approach for poststroke patients. “The Nintendo Wii Fit” game was used more than other games. The reviewed games were mostly operated to balance training and limb mobilization. Based on the evaluation results of the utilized games, only in three studies, applied games were not effective. In other studies, games had effective outcomes for target body members.

Conclusions

The results indicate that modern games are efficient in poststroke patients' physical rehabilitation and can be used alongside conventional methods.

Differences Between Exergaming Rehabilitation and Conventional Physiotherapy on Quality of Life in Parkinson's Disease: A Systematic Review and Meta-Analysis

Parkinson's disease (PD) is a neurodegenerative condition with both motor and non-motor symptoms affecting the quality of life (QoL) of older adults. Exergaming rehabilitation allows the interaction of the subject with digital games through the implementation of repetitive functional activities. Conventional physiotherapy uses patient-centered programs that include a variety of active exercises. The aim of this review was to look into the effectiveness of exergaming rehabilitation on the QoL of people with PD and compare it with conventional physiotherapy. Five electronic databases were searched for eligible studies until February 2021. For the statistical analysis, the mean, standard deviation, and 95% confidence interval were used to calculate effect sizes between groups. To determine heterogeneity, statistical index I ² was used. A total of 548 participants were included in 14 studies. Exergaming rehabilitation related with improved QoL (p = 0.687, 95% CI: -1.682 to -0.734), balance (p = 0.039, 95% CI: 0.364-13.689), (p = 0.018, 95% CI: 0.446-4.830), and gait (p = 0.005, 95% CI: 0.351-1.924). No significant difference was found between groups regarding the Unified Parkinson's Disease Rating Scale (p = 0.196, 95% CI: -5.970 to 1.225) and for the Timed Up and Go Test (p = 0.12, 95% CI: 0.446-4.830). Exergames as a rehabilitation method can be used to provide alternative interactive intervention with positive results for QoL in people with PD. Further investigation is needed to assess the effect on mental health in this population group.

Interventions Within the Scope of Occupational Therapy to Improve Activities of Daily Living, Rest, and Sleep in People With Parkinson's Disease: A Systematic Review

IMPORTANCE

People with Parkinson's disease (PD) commonly experience difficulty in performing activities of daily living (ADLs), which affects their perceived quality of life.

OBJECTIVE

To examine the evidence for the effectiveness of interventions within the scope of occupational therapy to improve performance and participation in ADLs, rest, and sleep in adults with PD.

DATA SOURCES

Databases searched were MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane Collection. Included articles were published between January 2011 and December 2018. Study Selection and Data Collection: Articles describing Level 1b, 2b, and 3b studies that examined outcomes related to ADLs, rest, and sleep in people with PD were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

FINDINGS

Forty-five articles (10 Level 1b, 27 Level 2b, and 8 Level 3b) met the inclusion criteria.

CONCLUSIONS AND RELEVANCE

Strong strength of evidence was found to support inpatient multidisciplinary intensive rehabilitation treatment (MIRT) to improve ADLs, and moderate strength of evidence that MIRT improves sleep performance. Low strength of evidence was present for outpatient occupational therapy to improve ADL and sleep outcomes. Low strength of evidence was found for resistance exercise programs to improve ADLs, but moderate strength of evidence indicates that multimodal exercise programs and targeted exercise programs can improve ADLs. Low to moderate strength of evidence suggested that alternative therapies and cognitive-behavioral therapy have a positive impact on ADLs and sleep. These results can be used to inform evidence-based occupational therapy practice. What This Article Adds: This article provides information for practitioners on the effectiveness of interventions within the scope of occupational therapy practice to improve ADLs and sleep.

Effects of Nintendo Ring Fit Adventure Exergame on Pain and Psychological Factors in Patients with Chronic Low Back Pain

Objective: In recent years, there has been an increase in research on the therapeutic effects of exergaming, but there have been few studies on these types of interventions for chronic low back pain. In this study, we hypothesized that the Nintendo Ring Fit Adventure (RFA) exergame would be effective for patients with chronic low back pain, and we conducted a randomized prospective longitudinal study. Materials and Methods: Patients with chronic low back pain were included in this study. Twenty randomly selected patients (9 males and 11 females, mean age 49.3 years) were included in the RFA group, and RFA exergaming was performed once a week for 40 minutes for 8 weeks. Twenty patients (12 males and 8 females, mean age 55.60 years) served as the control group and received oral treatment for 8 weeks. Pain and psychological scores (pain self-efficacy, pain catastrophizing, and kinesiophobia) were measured and analyzed before and after 8 weeks of treatment in both groups. Results: In the RFA group, low back pain, buttock pain, and pain self-efficacy were significantly improved after 8 weeks of RFA exergaming, but there was no significant improvement in lower limb numbness, pain catastrophizing, or kinesiophobia. In the control group, no significant improvement was observed after 8 weeks of oral treatment. Conclusion: RFA exergaming increased pain self-efficacy and reduced pain in patients with chronic low back pain. Future treatment protocols should be developed to improve pain self-efficacy. Approval code: 2894, School of Medicine, Chiba University.

Video Game-Based Rehabilitation Approach for Individuals Who Have Undergone Upper Limb Amputation: Case-Control Study

Background

Brain plasticity is an important factor in prosthesis usage. This plasticity helps with brain adaptation to learn new movement and coordination patterns needed to control a prosthetic hand. It can be achieved through repetitive muscle training that is usually very exhausting and often results in considerable reduction in patient motivation. Previous studies have shown that a playful concept in rehabilitation can increase patient engagement and perseverance.

Objective

This study investigated whether the inclusion of video games in the upper limb amputee rehabilitation protocol could have a beneficial impact for muscle preparation, coordination, and patient motivation among individuals who have undergone transradial upper limb amputation.

Methods

Ten participants, including five amputee participants and five able-bodied participants, were enrolled in 10 1-hour sessions within a 4-week rehabilitation program. In order to investigate the effects of the rehabilitation protocol used in this study, virtual reality box and block tests and electromyography (EMG) assessments were performed. Maximum voluntary contraction was measured before, immediately after, and 2 days after interacting with four different EMG-controlled video games. Participant motivation was assessed with the Intrinsic Motivation Inventory (IMI) questionnaire and user evaluation survey.

Results

Survey analysis showed that muscle strength and coordination increased at the end of training for all the participants. The results of Pearson correlation analysis indicated that there was a significant positive association between the training period and the box and block test score (r₈=0.95, P<.001). The maximum voluntary contraction increment was high before training (6.8%) and in the follow-up session (7.1%), but was very small (2.1%) shortly after the training was conducted. The IMI assessment showed high scores for the subscales of interest, perceived competence, choice, and usefulness, but low scores for pressure and tension.

Conclusions

This study demonstrated that video games enhance motivation and adherence in an upper limb amputee rehabilitation program. The use of video games could be seen as a complementary approach for physical training in upper limb amputee rehabilitation.

Effects of Virtual Reality with Motor Imagery Techniques in Patients with Parkinson's Disease: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Parkinson's disease (PD) is one of the most common neurological disorders, of insidious onset, with major motor symptomatology including bradykinesia, rest tremor, rigidity, and postural disturbances. Virtual reality (VR) and motor imagery (MI) are among the more innovative techniques for the rehabilitation of patients with PD which promote motor learning both through explicit and implicit processes. This study is unique in that it will examine the combined effects of VR and MI on motor function, balance and activities of daily living (ADLs) in patients with PD.

OBJECTIVE

The aim of this work is to investigate the effects of VR with MI techniques in addition to routine physical therapy on motor function, balance, and ADLs in patients with PD.

METHODS

This is a two-armed parallel design, single-blinded (assessor blinded), single-centered, randomized controlled trial, and the study protocol is based on SPIRIT guidelines. Thirty-four patients with PD (Modified Hoehn and Yahr stages I-III) will be randomly allocated with a 1:1 ratio into Group A (control group) and Group B (treatment group). Group A will be given routine physical therapy in 40-min sessions and 20 min of walking and cycling with a short period of rest, every alternate day (3 days per week) for 12 weeks, while for Group B routine physical therapy protocols along with VR and MI will be used in 60-min sessions, every alternate day (3 days per week) for 12 weeks. The primary outcome measures are as follows: (i) the Unified PD Rating Scale (UPDRS; part III), (ii) the Berg Balance Scale (BBS), and the Activities-Specific Balance Confidence Scale (ABC). The secondary outcome measure is the UPDRS (part II). Assessments will be recorded at baseline, the sixth and twelfth weeks of therapy, and 1 month after the discontinuation of therapy. Clinical Study Registration: This randomized controlled prospective study was registered with the Iranian Registry of clinical trials (IRCT20200221046567N1) on April 1, 2020 (https://www.irct.ir/trial/46073).

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

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

Nintendo WiiTM versus Xbox KinectTM for functional locomotion in people with Parkinson's disease: a systematic review and network meta-analysis

Purpose: To investigate the effectiveness of commercial exergames treatments on people with Parkinson's disease (PD), a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCT) was performed to evaluate functional locomotion effects in patients with PD.Methods: A comprehensive search on PubMed, Embase, Cochrane Controlled Trials Register, the Cochrane, and other databases without language restrictions was conducted. References and reviews were cross-checked for possible studies. RCTs from 2012 were included. Seven studies with 236 participants were included in the NMA that used a random-effect Frequentist model to investigate the standard mean difference of pooled effect sizes change in functional locomotion between baseline and delayed retention tests on six comparisons.Results: The direct comparisons Kinect: Control (n = 4), Wii: Control (n = 5) and the indirect-network comparison Kinect: Wii (n = 1) determine that Nintendo Wii™ may be the best choice in functional locomotion improvements.Conclusions: These network meta-analytic findings show that Kinect and Wii show immediate positive effects on functional locomotion in people with PD. Compared with Kinect RCTs, Wii may be considered the best therapy for providing functional recovery in PD.Implications for rehabilitationExergames rehabilitation reveals intervention benefits for functional locomotion in people with PD.In patients with cognitive disorders, Wii's platform can be considered a visual reference and a cue to facilitate patients with freezing.Nintendo Wii seems to be a better device for locomotion rehabilitation in people with PD than Xbox Kinect.

Comparison of virtual reality exercise versus conventional exercise on balance in patients with functional ankle instability: A randomized controlled trial

BACKGROUND

Recently, a variety of virtual reality (VR)-based interventions have been studied. However, they were only partially applied to physical therapy.

OBJECTIVE

The present study investigated the effects of a VR exercise program by comparing the results of VR and conventional exercise on balance in patients with functional ankle instability (FAI).

METHODS

Twenty-one participants with symptoms of FAI participated in this study. In the VR training program, the strength and balance exercises were done for 10 minutes each using a program included in the Nintendo Wii Fit Plus for VR intervention. In the conventional program, four ankle strength exercises using the TheraBand and the balance exercises were performed for 10 minutes each. Static and dynamic balance were measured in the overall, anterior-posterior, and medial-lateral directions.

RESULTS

Static balance in the VR exercise was significantly lower in the overall direction than in the conventional exercise. Dynamic balance in the virtual reality exercise was significantly lower than in the conventional exercise at level 2, level 4, and level 8 balance in the medial-lateral direction.

CONCLUSIONS

This study has shown that VR exercise is more effective in the overall direction (static) and medial-lateral direction (dynamic) of balance than conventional method in patients with FAI.

Hospital-to-Home Transition for Older Patients: Using Serious Games to Improve the Motivation for Rehabilitation – a Qualitative Study

Traditional physiotherapy is often perceived as repetitive and boring by patients, leading to issues in maintaining their interest and performing the required exercises. This paper investigates older patients’ engagement and motivation for physical activity using a serious game-based rehabilitation compared to a control group using a standard care therapy, during hospitalization. We conducted a randomized clinical trial with 57 geriatric patients and demonstrated that the serious game-based rehabilitation was as efficient as the standard rehabilitation program in terms of improving their functional capacity. In this paper, we mainly focus on reporting qualitative analysis of the patient’s behavior change thorough the intervention. The intervention lasted 3 weeks. Semi-structured interviews, including all the participants, were conducted before and after the intervention. Patients’ attitudes towards rehabilitation process, physical activity and innovation technology were investigated. Motivation to be active following the intervention were explored. Participants admitted feeling bored at the hospital and only following along the care process routine. Enthusiasm towards the progress brought by technological solution was observed. At the end of the hospital stay, the serious game-based rehabilitation received positive feedback. Patients felt more active and observed significant improvement of their general condition. The analysis suggests that patients participating in the gamified rehabilitation are more motivated. Several recommendations on designing serious game for elderly rehabilitation are proposed.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Exergames vs. traditional exercise: investigating the influencing mechanism of platform effect on subthreshold depression among older adults

OBJECTIVE

This study aimed to examine the influencing mechanism of exercise platform effect on subthreshold depression among older adults by comparing exergames and traditional exercise.

METHOD

One hundred and two Singaporean older adults were assigned to either playing Wii exergames or performing traditional exercise programs once a week, for six weeks.

RESULTS

Results confirmed a direct negative platform effect on subthreshold depression and further supported the mediation role of positive emotions in the platform effect. It implied that exergames led to higher positive emotions than traditional exercise, which further reduced the subthreshold depression among older adults. Self-efficacy was not supported to be a significant mediator in the relations between exercise platform and subthreshold depression.

CONCLUSION

A better understanding of the mechanisms behind the antidepressant effects of exercise platform would not only provide additional insight into a possible causal association, but also inspire the future use of exergames in the treatment of subthreshold depression.

The feasibility, acceptability and outcomes of exergaming among individuals with cancer: a systematic review

Background

Individuals with cancer have reduced quality of life, functionality, range of motion, strength, and an increase in pain and fatigue. Exergaming appears to be an effective rehabilitation tool for Parkinson’s disease, multiple sclerosis and post-stroke patients to improve functionality, balance and quality of life; however, the usefulness of exergaming in individuals with cancer is unknown. The aim of this systematic review is to describe exergaming interventions delivered to adults with a current or previous cancer diagnosis and to report the feasibility, acceptability and outcomes of such interventions.

Methods

Studies reporting on exergaming interventions delivered to individuals with a current or previous cancer diagnosis were included. 12 electronic databases were searched. Eight articles (seven interventions) were identified. Data were extracted and assessed for quality by two reviewers.

Results

Three interventions were delivered at hospital, two at home, one at a clinical laboratory, and one did not report. Two interventions were delivered by a physiotherapist, two by an occupational therapist, and one by a nurse, research staff and an exercise physiologist. The Nintendo Wii was used in four of seven studies, whilst the remaining three used the IREX system, BrightArm Duo Rehabilitation System or a custom made exergame. Studies showed that most participants enjoyed the exergaming intervention, and would recommend their use, with some preferring exergaming over standard care interventions. Adherence rates and enjoyment appear greater during exergaming than standard care. Exergaming interventions appear to support improvements balance, function, physical activity levels, strength, fatigue, emotions, cognition and pain.

Conclusion

Exergaming interventions delivered to individuals with cancer show great heterogeneity; differing in duration, frequency and gaming platform. The disease stage and severity of those included, and the outcome measures assessed also vary widely making it difficult to conclude its effectiveness at this time. However, adherence rates and enjoyment appear greater during exergaming compared to standard care, supporting the feasibility and acceptability of this type of intervention delivery for adults with cancer.

Training healthy persons and individuals with Parkinson's disease to use Xbox Kinect games: a preliminary study

Background/Aims:

Individuals with Parkinson's disease, besides the motor and cognitive symptoms may even present deficits in the motor learning. A recent therapeutic approach involves virtual reality that offers elements that can minimize the difficulties in the learning process. Recently, the therapeutic potential of Nintendo Wii® gaming device for rehabilitation of patients with Parkinson's disease has been showing positive results, but studies related to the use of the Kinect for XboxTM are still scarce. The present study aimed to investigate the effects of motor and cognitive demands of six Kinect for Xbox 360TM games on the learning of patients with Parkinson's disease, comparing it with healthy individuals.

Methods:

A total of 19 adults, 8 with idiopathic Parkinson's disease and 11 healthy adults participated in a program which included 10 training sessions and had their scores registered three times.

Findings:

The results showed that in four of those games, patients with Parkinson's disease showed an ability to improve and keep their performance, but not in the other two games, similar to healthy adults.

Conclusions:

It was concluded that motor and cognitive abilities affected by Parkinson's disease may be improved with the use of virtual training proposed in this study. Some of the games and gaming devices features can influence the learning process, even in healthy adults.

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

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

The feasibility and positive effects of a customised videogame rehabilitation programme for freezing of gait and falls in Parkinson's disease patients: a pilot study

BACKGROUND

Freezing of gait and falls represent a major burden in patients with advanced forms of Parkinson's disease (PD). These axial motor signs are not fully alleviated by drug treatment or deep-brain stimulation. Recently, virtual reality has emerged as a rehabilitation option for these patients. In this pilot study, we aim to determine the feasibility and acceptability of rehabilitation with a customised videogame to treat gait and balance disorders in PD patients, and assess its effects on these disabling motor signs.

METHODS

We developed a customised videogame displayed on a screen using the Kinect system. To play, the patient had to perform large amplitude and fast movements of all four limbs, pelvis and trunk, in response to visual and auditory cueing, to displace an avatar to collect coins and avoid obstacles to gain points. We tested ten patients with advanced forms of PD (median disease duration = 16.5 years) suffering from freezing of gait and/or falls (Hoehn&Yahr score ≥ 3) resistant to antiparkinsonian treatment and deep brain stimulation. Patients performed 18 training sessions during a 6-9 week period. We measured the feasibility and acceptability of our rehabilitation programme and its effects on parkinsonian disability, gait and balance disorders (with clinical scales and kinematics recordings), positive and negative affects, and quality of life, after the 9th and 18th training sessions and 3 months later.

RESULTS

All patients completed the 18 training sessions with high feasibility, acceptability and satisfaction scores. After training, the freezing-of-gait questionnaire, gait-and-balance scale and axial score significantly decreased by 39, 38 and 41%, respectively, and the activity-balance confidence scale increased by 35%. Kinematic gait parameters also significantly improved with increased step length and gait velocity and decreased double-stance time. Three months after the final session, no significant change persisted except decreased axial score and increased step length and velocity.

CONCLUSIONS

This study suggests that rehabilitation with a customised videogame to treat gait and balance disorders is feasible, well accepted, and effective in parkinsonian patients. These data serve as preliminary evidence for further larger and controlled studies to propose this customised videogame rehabilitation programme at home.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02469350 .

The determination of the validity of an application-based knee-training device

The goals of knee rehabilitation are to improve range of motion and muscle status. The aim of the study was to investigate accuracy and reproducibility of a newly designed knee-training device (KT) under standardized laboratory conditions.Two application-based software programs, one to measure maximum force and the other intended to improve users' coordination were developed to be used on a tablet during exercises, wirelessly connected to KT placed under the popliteal fossa.KT was loaded for 20 intervals of 15 seconds (s) ranging between 0-350 Newton (N) each. The interval of times was chosen to be enough to take right measurement for accurate results. In addition, a 300-s continuous measurement was undertaken. The pressure readings were developed through a servo-hydraulic system and used as reference values. KT results were compared with the reference values to assess its accuracy. In addition, KT was tested on a force-measuring platform in a close to reality measurement.Based on Bland-Altman plots, the mean difference between KT and material testing machine was -0.63 N (0.4%), between KT and force-measuring platform was -0.11 N (0.7%), which proves the accuracy of its result.Laboratory experiments confirm that KT delivers precise and reproducible values, which provide base for clinical trials.

The efficacy of virtual reality assisted versus traditional rehabilitation intervention on individuals with functional ankle instability: a pilot randomized controlled trial

PURPOSE

Virtual reality (VR) training, a virtual environment commonly generated by computer systems, may enhance the therapeutic efficacy of functional rehabilitation programmes. The aim of this study was to investigate the efficacy of a VR assisted intervention (VRAI) versus traditional rehabilitation intervention (TRI) on functional ankle instability (FAI).

METHODS

A single-blind randomized controlled study was conducted with 10 subjects for each group. The VRAI was conducted with the Nintendo Wii Fit Plus, whilst the TRI was conducted with a series of exercises with theraband. The muscle strength change of the two groups and the difference between pre and post interventions for each group were compared.

RESULTS

The VRAI group had less improvement in the muscle strength of all ankle motions than did the TRI group (p > .05). The VRAI group had a greater improvement in muscle strength of plantar flexion than other motions, whilst the TRI group had an improvement in muscle strength of all ankle motions (p < .05).

CONCLUSIONS

The effects of VR training for the condition of FAI were not comparable to conventional training. However, VR training may be added to the conventional training programme as an optional for the condition of FAI. Implications for Rehabilitation Functional ankle instability (FAI) is subjective feelings of ankle instability resulting from proprioceptive and neuromuscular deficits in which individuals may experience "giving way" condition of the ankle. Therapeutic applications of virtual reality (VR) may be comparable to traditional rehabilitation interventions (TRI) in the rehabilitation of individuals with FAI. However, there is no definitive evidence for the issue. Integrating low-cost VR into functional rehabilitation programme can provide insight into an issue of whether it can be replaced with traditional therapeutic approaches. Although, the efficacy of VR application on strengthening muscles is unable to compare to traditional strengthening programmes, it may be considered an optional treatment based on the proprioceptive improvements.

Augmented visual feedback-aided interventions for motor rehabilitation in Parkinson's disease: a systematic review

PURPOSE

A systematic review was performed to (1) evaluate the effectiveness of augmented visual feedback-based treatments for motor rehabilitation in Parkinson's disease, and (2) examine treatment design factors associated with enhanced outcomes following these treatments.

METHODS

Eight databases were searched from their start-date up to January 2017 using the key terms Parkinson's Disease and augmented visual feedback. Two independent raters screened the abstracts and full articles for inclusion. Relevant data were extracted and summarized, and methodological quality of accepted articles was assessed.

RESULTS

Eight single-group studies and 10 randomized control trials were included in the review. Augmented visual feedback-based treatments resulted in improved outcomes with small to large effect sizes post-treatment for the majority of impairment, activity, participation, and global motor function measures, and these improvements were often superior to traditional rehabilitation/education programs. Enhanced treatment outcomes were observed in studies that provided large amounts and high intensities of treatment; gamified feedback; and provided knowledge of performance feedback in real-time on 100% of practice trials.

CONCLUSION

Augmented visual feedback appears to be a useful motor rehabilitation tool in Parkinson's disease; however, high-quality, rigorous studies remain limited. Future studies should consider factors that enhance rehabilitation outcomes when designing augmented visual feedback-based interventions. Implications for rehabilitation Augmented visual feedback is a useful tool for motor rehabilitation in Parkinson's disease; augmented visual feedback-based treatments are often superior to traditional programs. These treatments are associated with improved outcomes in impairment, activity, participation, and global motor function domains. Rehabilitation professionals can optimize their use of augmented visual feedback-based treatments by providing large amounts and a high intensity of treatment, gamifying feedback, and providing knowledge of performance feedback in real-time and at a high frequency.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Complementary and Alternative Medicine and Exercise in Nonmotor Symptoms of Parkinson's Disease

The use of complementary and alternative medicine (CAM) therapy in nonmotor symptoms (NMS) for Parkinson disease (PD) is growing worldwide. Well-performed, systematic evidence-based research is largely lacking in this area and many studies include various forms of CAM with small patient numbers and a lack of standardization of the approaches studied. Taichi, Qigong, dance, yoga, mindfulness, acupuncture, and other CAM therapies are reviewed and there is some evidence for the following: Taichi in sleep and PDQ39; dance in cognition, apathy, and a mild trend to improved fatigue; yoga in PDQ39; and acupuncture in depression, PDQ39, and sleep. Exercise including occupational therapy (OT) and physical therapy (PT) has been studied in motor symptoms of PD and balance but only with small studies with a mounting evidence base for use of exercise in NMS of PD including PDQ39, sleep, fatigue, depression, and some subsets of cognition. Studies of OT and PT largely show some benefit to depression, apathy, and anxiety. Sustainability of an improvement has not been shown given short duration of follow up. Finding optimal control groups and blind for these interventions is also an issue. This is a very important area of study since patients want to be self-empowered and they want guidance on which form of exercise is the best. Additionally, evidence for PT and OT in NMS would give added weight to get these interventions covered through medical insurance.

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

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

A systematic review of active video games on rehabilitative outcomes among older patients

BACKGROUND

Although current research supports the use of active video games (AVGs) in rehabilitation, the evidence has yet to be systematically reviewed or synthesized. The current project systematically reviewed literature, summarized findings, and evaluated the effectiveness of AVGs as a therapeutic tool in improving physical, psychological, and cognitive rehabilitative outcomes among older adults with chronic diseases.

METHODS

Seven databases (Academic Search Complete, Communication & Mass Media Complete, ERIC, PsycINFO, PubMed, SPORTDiscus, and Medline) were searched for studies that evaluated the effectiveness of AVG-based rehabilitation among older patients. The initial search yielded 946 articles; after evaluating against inclusion criteria and removing duplicates, 19 studies of AVG-based rehabilitation remained.

RESULTS

Most studies were quasi-experimental in design, with physical functioning the primary outcome investigated with regard to the use of AVGs in rehabilitation. Overall, 9 studies found significant improvements for all study outcomes, whereas 9 studies were mixed, with significant improvements on several study outcomes but no effects observed on other outcomes after AVG-based treatments. One study failed to find any benefits of AVG-based rehabilitation.

CONCLUSION

Findings indicate AVGs have potential in rehabilitation for older patients, with several randomized clinical trials reporting positive effects on rehabilitative outcomes. However, existing evidence is insufficient to support the advantages of AVGs over standard therapy. Given the limited number of studies and concerns with study design quality, more research is warranted to make more definitive conclusions regarding the ability of AVGs to improve rehabilitative outcomes in older patients.

The Effect of Balance Training on Postural Control in Patients with Parkinson's Disease Using a Virtual Rehabilitation System

OBJECTIVES

Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by motor clinical alterations among others. Postural problems have serious consequences for patients, not only limiting their daily life but also increasing some risks, like the risk of fall. Inadequate postural control and postural instability is a major problem in PD patients. A Virtual Motor Rehabilitation System (VMR) has been tested in patients with PD in the intervention period. Our purpose was to analyze the evolution of the spatial postural control during the intervention period, to see if there are any changes caused precisely by this intervention.

METHODS

Ten people with PD carried out 15 virtual rehabilitation sessions. We tested a groundbreaking system based on Virtual Motor Rehabilitation in two periods of time (baseline evaluation and final evaluation). In the training sessions, the participants performed a customizable treatment using a low-cost system, the Active Balance Rehabilitation system (ABAR). We stored the pressure performed by the participants every five hundredths of a second, and we analyzed the patients' pressure when they maintained their body on the left, on the right, and in the center in sitting position. Our system was able to measure postural control in every patient in each of the virtual rehabilitation sessions.

RESULTS

There are no significant differences in the performance of postural control in any of the positions evaluated throughout the sessions. Moreover, the results show a trend to an improvement in all positions. This improvement is especially remarkable in the left/right positions, which are the most important positions in order to avoid problems such as the risk of fall. With regard to the suitability of the ABAR system, we have found outstanding results in enjoyment, success, clarity, and helpfulness.

CONCLUSIONS

Although PD is a progressive neurodegenerative disorder, the results demonstrate that patients with PD maintain or even improve their postural control in all positions. We think that the main factor influencing these results is that patients use more of their available cognitive processing to improve their postural control. The ABAR system allows us to make this assumption because the system requires the continuous attention of patients, promoting cognitive processing.

Game-Based Rehabilitation for Myoelectric Prosthesis Control

Background

A high number of upper extremity myoelectric prosthesis users abandon their devices due to difficulties in prosthesis control and lack of motivation to train in absence of a physiotherapist. Virtual training systems, in the form of video games, provide patients with an entertaining and intuitive method for improved muscle coordination and improved overall control. Complementary to established rehabilitation protocols, it is highly beneficial for this virtual training process to start even before receiving the final prosthesis, and to be continued at home for as long as needed.

Objective

The aim of this study is to evaluate (1) the short-term effects of a commercially available electromyographic (EMG) system on controllability after a simple video game-based rehabilitation protocol, and (2) different input methods, control mechanisms, and games.

Methods

Eleven able-bodied participants with no prior experience in EMG control took part in this study. Participants were asked to perform a surface EMG test evaluating their provisional maximum muscle contraction, fine accuracy and isolation of electrode activation, and endurance control over at least 300 seconds. These assessments were carried out (1) in a Pregaming session before interacting with three EMG-controlled computer games, (2) in a Postgaming session after playing the games, and (3) in a Follow-Up session two days after the gaming protocol to evaluate short-term retention rate. After each game, participants were given a user evaluation survey for the assessment of the games and their input mechanisms. Participants also received a questionnaire regarding their intrinsic motivation (Intrinsic Motivation Inventory) at the end of the last game.

Results

Results showed a significant improvement in fine accuracy electrode activation (P<.01), electrode separation (P=.02), and endurance control (P<.01) from Pregaming EMG assessments to the Follow-Up measurement. The deviation around the EMG goal value diminished and the opposing electrode was activated less frequently. Participants had the most fun playing the games when collecting items and facing challenging game play.

Conclusions

Most upper limb amputees use a 2-channel myoelectric prosthesis control. This study demonstrates that this control can be effectively trained by employing a video game-based rehabilitation protocol.

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

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

Virtual reality for rehabilitation in Parkinson's disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Does a Combination of Virtual Reality, Neuromodulation and Neuroimaging Provide a Comprehensive Platform for Neurorehabilitation? - A Narrative Review of the Literature

In the last decade, virtual reality (VR) training has been used extensively in video games and military training to provide a sense of realism and environmental interaction to its users. More recently, VR training has been explored as a possible adjunct therapy for people with motor and mental health dysfunctions. The concept underlying VR therapy as a treatment for motor and cognitive dysfunction is to improve neuroplasticity of the brain by engaging users in multisensory training. In this review, we discuss the theoretical framework underlying the use of VR as a therapeutic intervention for neurorehabilitation and provide evidence for its use in treating motor and mental disorders such as cerebral palsy, Parkinson’s disease, stroke, schizophrenia, anxiety disorders, and other related clinical areas. While this review provides some insights into the efficacy of VR in clinical rehabilitation and its complimentary use with neuroimaging (e.g., fNIRS and EEG) and neuromodulation (e.g., tDCS and rTMS), more research is needed to understand how different clinical conditions are affected by VR therapies (e.g., stimulus presentation, interactivity, control and types of VR). Future studies should consider large, longitudinal randomized controlled trials to determine the true potential of VR therapies in various clinical populations.

Nintendo Wii Fit for balance rehabilitation in patients with Parkinson's disease: A comparative study

BACKGROUND

Impaired postural stability places individuals with Parkinson's disease (PD) at an increased risk for falls.

OBJECTIVE

We evaluated the effectiveness of 10 vs. 15 sessions of Nintendo Wii Fit for balance recovery for outpatients PD.

METHODS

Twenty-seven patients, 48.1% female (66 ± 8 years), with PD. Patients with PD were consecutively assigned to one of two groups receiving either 10 or 15 sessions (low dose or high dose group, respectively) with Nintendo Wii Fit in recovering balancing ability. All outcome measures were collected at baseline, immediately following the intervention period, and 1-month following the end of the intervention.

MAIN OUTCOME MEASURE

Falls risk test (FRT), Stability index (PST), Berg balance scale (BBS) and Tinetti scale.

RESULTS

The patients undergoing the 10 sessions demonstrated significantly improvement on the balance performances (Tinetti balance and gait scales, BBS and BSF) (all, P < 0.05) as those undergoing 15 treatment with Nintendo Wii Fit, but no significant group effect or group-by-time interaction was detected for any of them, which suggests that both groups improved in the same way.

CONCLUSIONS

The results suggest that functional improvement can be made in fewer visits during outpatient rehabilitation sessions with Nintendo Wii Fit improving the efficiency of intervention.

Training Advanced Practice Providers to Collect Functional Outcomes After Fragility Fractures

Objective:

The objective of this study was to determine whether advanced practice providers could learn to collect objective functional assessment data accurately and efficiently with commercially available devices that measure kinematics and kinetics (Nintendo Wii Balance Board [WBB] and Level Belt [LB]) to aid in the assessment of fall risk and outcomes after fragility fractures.

Methods:

Nine advanced practice providers participated in a 1-hour clinical assessment tools (CATs) training session on equipment use, providing standardized instructions, and practice of the testing procedures. Afterward, they participated in a skills demonstration evaluation and completed a postsession survey.

Results:

Participants successfully achieved a mean of 18.22 (standard deviation 1.56) of 20 performance measures. Of the incomplete or omitted tasks, the majority (10 of 16) occurred within the first of 3 CATs activities. Postsession survey results revealed that 9 of 9 participants reported that the 1 hour provided for training on the CATs was sufficient. All participants reported that after the training, they felt confident they could reliably carry out the tasks to test patients on both the WBB and the LB. The majority of participants reported that they believed that the WBB (7 of 9) and LB (8 out of 9) would be good assets to clinics in assessing patient functionality after fragility fractures.

Conclusion:

These results indicate that advanced practice providers can confidently learn and effectively test patients with the WBB and LB within 1 hour of training. In the future, adoption of CATs in the clinical setting may allow for objective, easy-to-use, portable, noninvasive, and relatively inexpensive measures to assess functional outcomes in patients with fragility fracture.

The Effects of Video Games on Cognition and Brain Structure: Potential Implications for Neuropsychiatric Disorders

Video games are now a ubiquitous form of entertainment that has occasionally attracted negative attention. Video games have also been used to test cognitive function, as therapeutic interventions for neuropsychiatric disorders, and to explore mechanisms of experience-dependent structural brain changes. Here, we review current research on video games published from January 2011 to April 2014 with a focus on studies relating to mental health, cognition, and brain imaging. Overall, there is evidence that specific types of video games can alter brain structure or improve certain aspects of cognitive functioning. Video games can also be useful as neuropsychological assessment tools. While research in this area is still at a very early stage, there are interesting results that encourage further work in this field, and hold promise for utilizing this technology as a powerful therapeutic and experimental tool.

Psychological Benefits of Nonpharmacological Methods Aimed for Improving Balance in Parkinson's Disease: A Systematic Review

Parkinson's disease (PD) is a serious condition with a major negative impact on patient's physical and mental health. Postural instability is one of the cardinal difficulties reported by patients to deal with. Neuroanatomical, animal, and clinical studies on nonparkinsonian and parkinsonian subjects suggest an important correlation between the presence of balance dysfunction and multiple mood disorders, such as anxiety, depression, and apathy. Considering that balance dysfunction is a very common symptom in PD, we can presume that by its management we could positively influence patient's state of mind too. This review is an analysis of nonpharmacological methods shown to be effective and successful for improving balance in patients suffering from PD. Strategies such as general exercise, robotic assisted training, Tai Chi, Qi Gong, Yoga, dance (such as tango or ballet), box, virtual reality-based, or neurofeedback-based techniques and so forth can significantly improve the stability in these patients. Beside this physical outcome, many methods have also shown effect on quality of life, depression level, enjoyment, and motivation to continue in practicing the method independently. The purpose of this review is to provide information about practical and creative methods designed to improve balance in PD and highlight their positive impact on patient's psychology.

A scoping review of video gaming in rehabilitation

PURPOSE

To examine the scope of the peer-reviewed literature on the use of commercially available video gaming in rehabilitation.

METHODS

Five databases (SCOPUS, Cochrane, PsycINFO, PubMed and CINAHL) were searched for articles published between January 1990 and January 2014. The reference lists of selected articles were also reviewed to identify other relevant studies.

RESULTS

Thirty articles met the inclusion criteria. Commercially available video gaming in rehabilitation was most commonly recommended by physiotherapists (50% or 15/30 studies) for populations at risk for falls or with decreased balance (67% or 19/30 studies). The most commonly used target outcomes were those assessing balance and/or fall prevention, with the Berg Balance Scale being the most frequently used (53% or 16/30 studies) outcome measure. The Nintendo Wii was the most prevalent gaming system (90% or 27/30 studies) used in the identified studies.

CONCLUSION

Video gaming in rehabilitation is widely used by clinicians. Preliminary findings show that video gaming technology can be applied across a wide variety of rehabilitation populations, with some evidence showing clinical gains in physical functioning (e.g. gait and balance). There is a need for more robust clinical trials evaluating the efficacy of using video game systems as an adjunct to conventional rehabilitation. Implications for Rehabilitation Video gaming is a readily available technology that has been suggested as an enjoyable and motivating activity that engages patients in rehabilitation programming. Video gaming is becoming an increasingly popular adjunct to traditional therapy. Video gaming is most commonly used by physical therapists in a hospital setting for those with balance impairments. Video gaming has been shown to improve functional outcomes.