Benefits of activity and virtual reality based balance exercise programmes for adults with traumatic brain injury: Perceptions of participants and their caregivers

The use of virtual reality for activities of daily living rehabilitation after brain injury: A scoping review

INTRODUCTION

Individuals with acquired brain injury (ABI) experience high rates of poor functional outcomes such as inability to complete activities of daily living (ADL). Occupational therapy needs to be customised to the individual's function, goals, and environment to facilitate improvement in ADLs after ABI. Virtual reality (VR) is a novel treatment approach that aims to improve skills within an individualised environment. This study aimed to review the current literature for the use of VR platforms that incorporate ADLs to improve functional outcomes after ABI.

METHODS

This review followed the six-stage framework by Arksey & O'Malley (2005). Electronic databases were searched for peer-reviewed journal articles based on inclusion and exclusion criteria.

RESULTS

One thousand and six hundred eighty articles were screened, including 413 full text articles and 13 articles were included for review. Among the 13 articles, six were RCTs and the rest were pre-post intervention studies. Studies largely used non-immersive VR platforms, which incorporated ADLs such as grocery shopping, aiming to improve functional outcomes.

CONSUMER AND COMMUNITY CONSULTATION

Consumer and community were not involved in executing this study.

CONCLUSION

This review suggests mixed results if VR is effective at treating upper limb, cognition, and ADL function after ABI. Using their clinical reasoning, occupational therapists can determine the suitability of VR for ADL rehabilitation for specific patient populations and settings. Plain Language Summary Individuals who sustain an acquired brain injury can have difficulty performing their daily activities such as, making a meal or getting dressed, because of limited function (e.g., physical and cognitive problems). To help improve their ability to complete daily activities, occupational therapy needs to be customised to the individual's function, goals, and environment. Virtual reality is a new rehabilitation approach that allows individuals to improve their function in an individualised environment. In this study, we reviewed the current studies that have used virtual reality platforms that incorporate daily activities to improve function after acquired brain injury. We searched databases and screened the titles and abstracts of 1,680 studies. Then, 413 full-text studies were screened, and 13 studies were included. Studies mostly used non-immersive platforms to practise daily activities such as, grocery shopping, aiming to improve function after acquired brain injury. This review suggests mixed results if virtual reality can effectively treat function after acquired brain injury.

Virtual Exercise in Medicine: A Proof of Concept in a Healthy Population

BACKGROUND

Science is beginning to establish the benefits of the use of virtual reality (VR) in health care. This therapeutic approach may be an appropriate complementary treatment for some mental illnesses. It could prevent high levels of morbidity and improve the physical health of patients. For many years, the literature has shown the health benefits of physical exercise. Physical exercise in a VR environment may improve the management of mild to moderate mental health conditions. In this context, we developed a virtual environment combined with an ergocycle (the augmented physical training for isolated and confined environments [APTICE] system).

OBJECTIVE

This study aims to investigate the impact of physical exercise in a VR environment.

METHODS

A total of 14 healthy participants (11 men and 3 women; mean age 43.28, SD 10.60 years) undertook 15 minutes of immersive physical exercise using the system. Measures included mindfulness and immersion disposition, subjective perceptions of sensory information, user experience, and VR experience (ie, psychological state, flow, and presence).

RESULTS

First, the APTICE system appears to be a useful tool because the user experience is positive (subscales in the AttrakDiff questionnaire: pragmatic quality=0.99; hedonic quality-stimulation=1.90; hedonic quality-identification=0.67; attractiveness=1.58). Second, the system can induce a positive psychological state (negative emotion, P=.06) and an experience of flow and presence (P values ranging from <.001 to .04). Third, individual immersive and mindful disposition plays a role in the VR experience (P values ranging from <.02 to .04). Finally, our findings suggest that there is a link between the subjective perception of sensory information and the VR experience (P values ranging from <.02 to .04).

CONCLUSIONS

These results indicate that the device is well accepted with positive psychological and exteroceptive outcomes. Overall, the APTICE system could be a proof of concept to explore the benefits of virtual physical exercise in clinical medicine.

The attention atlas virtual reality platform maps three-dimensional (3D) attention in unilateral spatial neglect patients: a protocol

BACKGROUND

Deficits in visuospatial attention, known as neglect, are common following brain injury, but underdiagnosed and poorly treated, resulting in long-term cognitive disability. In clinical settings, neglect is often assessed using simple pen-and-paper tests. While convenient, these cannot characterise the full spectrum of neglect. This protocol reports a research programme that compares traditional neglect assessments with a novel virtual reality attention assessment platform: The Attention Atlas (AA).

METHODS/DESIGN

The AA was codesigned by researchers and clinicians to meet the clinical need for improved neglect assessment. The AA uses a visual search paradigm to map the attended space in three dimensions and seeks to identify the optimal parameters that best distinguish neglect from non-neglect, and the spectrum of neglect, by providing near-time feedback to clinicians on system-level behavioural performance. A series of experiments will address procedural, scientific, patient, and clinical feasibility domains.

RESULTS

Analyses focuses on descriptive measures of reaction time, accuracy data for target localisation, and histogram-based raycast attentional mapping analysis; which measures the individual's orientation in space, and inter- and intra-individual variation of visuospatial attention. We will compare neglect and control data using parametric between-subjects analyses. We present example individual-level results produced in near-time during visual search.

CONCLUSIONS

The development and validation of the AA is part of a new generation of translational neuroscience that exploits the latest advances in technology and brain science, including technology repurposed from the consumer gaming market. This approach to rehabilitation has the potential for highly accurate, highly engaging, personalised care.

The effect of self-reported balance confidence on community integration after brain injury: an observational study

OBJECTIVE

To evaluate the correlation between self-reported balance confidence and community integration related to home management for community-dwelling adults with acquired brain injury (ABI).

METHODS

This is a study of 141 participants over the age of 18 with a history of ABI, living in the community, who completed an online survey. The survey included a series of demographic questions followed by the Activities-Specific Balance Confidence Scale (ABC) and the Home Integration subscale of the Community Integration Questionnaire (CIQ-H).

RESULTS

Data from 119 completed surveys were included in the analysis. Significant positive correlations were found between the ABC and the CIQ-H total scores (rs = 0.241, p = 0.008). There was no significant difference between CIQ-H total scores in individuals by injury type (traumatic vs non-traumatic) or by level of severity (mild, moderate, severe) (p > 0.05). There was no significant difference between ABC total scores by injury type (p > 0.05).

CONCLUSIONS

Higher levels of balance confidence may be associated with improved community integration related to home management for individuals with traumatic and non-traumatic BI. This study's results support future research to evaluate the integration of strategies to improve balance confidence as a component of interdisciplinary assessment and rehabilitation to maximize community integration in community-dwelling adults with ABI.

Home-Based Virtual Reality Exergame Program after Stroke Rehabilitation for Patients with Stroke: A Study Protocol for a Multicenter, Randomized Controlled Trial

It is essential for stroke patients to maintain their therapy even after discharging inpatient rehabilitation. This is because recovery is an ongoing process that requires consistent effort. Virtual reality exergame training (VRET) is becoming widely used in stroke rehabilitation to improve physical, social, and psychological outcomes. Home-based VRET may be a more convenient and accessible option for stroke rehabilitation. This study will aim to determine the effectiveness of home-based VRET for patients with stroke who have been discharged from the hospital. This trial will randomly assign 120 participants to 8 weeks of either a VRET (intervention group) or daily life (control group). The study will measure cardiopulmonary endurance, muscular strength, functional capacity, gait, activities of daily living, and quality of life. Our main objective is to determine whether it is safe for patients to undergo VRET at home after they have been discharged from the hospital with a doctor's note. Additionally, we aim to examine whether stroke patients are capable of exercising at home after being discharged from the hospital. This study's outcome could pave the way for developing more comprehensive exercise protocols for stroke patients. Our findings will provide valuable insights into the efficacy of VRET as a therapeutic tool for stroke patients.

Evaluating the Alterations Induced by Virtual Reality in Cerebral Small-World Networks Using Graph Theory Analysis with Electroencephalography

Virtual reality (VR), a rapidly evolving technology that simulates three-dimensional virtual environments for users, has been proven to activate brain functions. However, the continuous alteration pattern of the functional small-world network in response to comprehensive three-dimensional stimulation rather than realistic two-dimensional media stimuli requires further exploration. Here, we aimed to validate the effect of VR on the pathways and network parameters of a small-world organization and interpret its mechanism of action. Fourteen healthy volunteers were selected to complete missions in an immersive VR game. The changes in the functional network in six different frequency categories were analyzed using graph theory with electroencephalography data measured during the pre-, VR, and post-VR stages. The mutual information matrix revealed that interactions between the frontal and posterior areas and those within the frontal and occipital lobes were strengthened. Subsequently, the betweenness centrality (BC) analysis indicated more robust and extensive pathways among hubs. Furthermore, a specific lateralized channel (O1 or O2) increment in the BC was observed. Moreover, the network parameters improved simultaneously in local segregation, global segregation, and global integration. The overall topological improvements of small-world organizations were in high-frequency bands and exhibited some degree of sustainability.

Effects of 3D virtual reality motionless imagery training program with an avatar

The present study aimed to explore the effects of motionless imagery training with an avatar in virtual reality (VR) on emotion, cognition, and physiological response changes in healthy adults. Participants were 30 healthy adults aged between 19 and 35 years. All participants were randomly divided into the experimental group (n = 18), which executed the imagery training with an avatar in VR, or the control group (n = 12), which merely experienced the VR without an avatar. Both groups underwent the intervention, a 20-min session, 3 times a week for 6 weeks. VR experience questionnaires and physiological response changes were measured at pre- and post-test and emotional states and cognition tests were measured at pre-, post-, and follow-up test. The experimental group showed no significant changes in the Presence Questionnaire (PQ) and the Simulator Sickness Questionnaire (SSQ) after the intervention while the control group showed a significant decrease in the PQ after the intervention. In all emotional states, there were no significant differences in the interaction between times and groups. A significant main effect of time was revealed in all cognition tests except the delayed recall and the delayed recognition in K-Auditory Verbal Learning Test (K-AVLT). In physiological response changes, the experimental group showed significant improvements in the electromyogram (EMG) at rectus femoris on the left side after the intervention. Thus, imagery training with an avatar in VR can be considered to be effective for enhancements of cognitions and physiological response changes.

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.

The COVID-19 Pandemic and Overall Wellbeing: Mediating Role of Virtual Reality Fitness for Physical-Psychological Health and Physical Activity

Background

Virtual reality applications are made for various objectives such as business, entertainment, education, and healthcare. Anxiety, phobias, distress, disordered eating, drug addiction, panic disorder, post-traumatic stress disorder, schizophrenia, bipolar disorder, psychosis, depression, and autism spectrum disorders may benefit from virtual reality-based approaches. The 2019 coronavirus (COVID-19) pandemic has impacted the way we live, enjoy, study, sport, and socialize significantly. Virtual reality fitness technology gained much attention during the COVID-19 preventive measures time.

Objective

The present study explores the role of virtual reality fitness in improving overall wellbeing during the COVID-19 pandemic home isolation period in terms of physical-psychological health and physical activity.

Methods

A total of 2300 individuals were recruited using the snowball sampling technique to participate in the study. The primary data were collected using an anonymous web-based survey. SPSS-23 and Smart-PLS 3.2.9 software were used to analyze the data.

Results

The direct path coefficient analysis of the study constructs show that virtual reality fitness has (preventive measures -> virtual reality fitness -> overall wellbeing, preventive measures -> virtual reality fitness -> physical exercise, and preventive measures -> virtual reality fitness -> physical health) profound effects on the research participants’ mental and physical wellbeing of the study participants while indirect mediation analysis shows that virtual reality fitness has (preventive measures -> virtual reality fitness ->overall wellbeing, preventive measures -> virtual reality fitness -> physical exercise, preventive measures -> virtual reality fitness ->physical health) significant impacts.

Conclusion

Our study results concluded that house exercises through virtual reality fitness are a good substitute for public gyms and private group fitness programs during the first pandemic wave for physical-psychological and overall wellbeing. Virtual reality fitness technology can alleviate many of the challenges brought on by the epidemic, resulting in increased utilization.

Feasibility of virtual reality and treadmill training in traumatic brain injury: a randomized controlled pilot trial

OBJECTIVE

To evaluate the safety and efficacy of treadmill training with virtual reality compared to treadmill training alone and standard of care balance and mobility treatment in chronic traumatic brain injury (TBI).

PARTICIPANTS AND DESIGN

Thirty-one individuals with chronic TBI with self-reported and objective balance deficits participated in a 4-week 12 session intervention of treadmill training with virtual reality, treadmill training alone, or standard of care overground therapy.

OUTCOME MEASURES

Primary measures included recruitment and enrollment rates, retention, tolerance to intervention, completeness of outcome measures, and adverse events. Secondary measures included the Community Balance and Mobility Scale, 10 Meter Walk Test, 6 Minute Walk Test, and Timed Up and Go.

RESULTS

No serious adverse events were reported. All participants completed all training sessions and assessments at all time points. Recruitment, enrollment, and retention rates were high. All groups showed a trend toward improvement in all balance and mobility measures following treatment.

CONCLUSION

Virtual reality and treadmill training are safe and feasibile for individuals with TBI. Participants show improvements on balance and mobility measures following a 4-week intervention. Future research is needed to evaluate the efficacy of this intervention compared to other modes of balance and mobility training.

A Wearable Mixed Reality Platform to Augment Overground Walking: A Feasibility Study

Humans routinely modify their walking speed to adapt to functional goals and physical demands. However, damage to the central nervous system (CNS) often results in abnormal modulation of walking speed and increased risk of falls. There is considerable interest in treatment modalities that can provide safe and salient training opportunities, feedback about walking performance, and that may augment less reliable sensory feedback within the CNS after injury or disease. Fully immersive virtual reality technologies show benefits in boosting training-related gains in walking performance; however, they lack views of the real world that may limit functional carryover. Augmented reality and mixed reality head-mount displays (MR-HMD) provide partially immersive environments to extend the virtual reality benefits of interacting with virtual objects but within an unobstructed view of the real world. Despite this potential advantage, the feasibility of using MR-HMD visual feedback to promote goal-directed changes in overground walking speed remains unclear. Thus, we developed and evaluated a novel mixed reality application using the Microsoft HoloLens MR-HMD that provided real-time walking speed targets and augmented visual feedback during overground walking. We tested the application in a group of adults not living with disability and examined if they could use the targets and visual feedback to walk at 85%, 100%, and 115% of each individual’s self-selected speed. We examined whether individuals were able to meet each target gait speed and explored differences in accuracy across repeated trials and at the different speeds. Additionally, given the importance of task-specificity to therapeutic interventions, we examined if walking speed adjustment strategies were consistent with those observed during usual overground walking, and if walking with the MR-HMD resulted in increased variability in gait parameters. Overall, participants matched their overground walking speed to the target speed of the MR-HMD visual feedback conditions (all p-values > 0.05). The percent inaccuracy was approximately 5% across all speed matching conditions and remained consistent across walking trials after the first overall walking trial. Walking with the MR-HMD did not result in more variability in walking speed, however, we observed more variability in stride length and time when walking with feedback from the MR-HMD compared to walking without feedback. The findings offer support for mixed reality-based visual feedback as a method to provoke goal-specific changes in overground walking behavior. Further studies are necessary to determine the clinical safety and efficacy of this MR-HMD technology to provide extrinsic sensory feedback in combination with traditional treatments in rehabilitation.

Application of Virtual Reality Rehabilitation System for the assessment of postural control while standing in typical children and peers with neurodevelopmental disorders

BACKGROUND

The assessment of postural control in children is crucial, due to its central role in their overall development. However, a tool that objectively quantifies the difference in postural control between typical and atypical developing children is lacking. In this study, we introduce a new technology (Virtual Reality Rehabilitation System, VRRS) for assessing children's postural control.

RESEARCH QUESTION

Is this new assessment tool capable to highlight the differences between typical development (TD) and atypical development, (children with Developmental Coordination Disorder (DCD) and Cerebral Palsy (CP))?

METHODS

30 TD children, 20 children with DCD and 27 with CP (mean ages: 6.29 ± 2.74; 9.11 ± 2.65; 10.07 ± 3.89 years) were tested with the VRRS Tablet with stabilometric balance platform. Postural parameters, related to the movements of the Centre of Pressure (COP) were collected. A multivariate analysis of variance (MANOVA) followed by a post-hoc analysis has been carried out. Moreover, the influence of age, sex, clinical scores and sub-diagnoses on parameters of interest has been explored.

RESULTS

COP distance and sway area in the three groups (TD: 7.35 ± 2.32 mm, 101.70 ± 64.16 mm²/s; DCD: 12.05 ± 8.19 mm, 188.46 ± 231.23 mm²/s; CP: 13.25 ± 8.09 mm, 239.13 ± 313.83 mm²/s, respectively) and all other VRRS parameters were significantly different among the three groups (p-values between 0.028 and <0.001). The TD group showed significantly different values than CP (p from < 0.03 to < 0.001) but not than DCD (p = n.s.). Clinical scores showed to correlate with the COP distances and Root Mean Square distances in all subgroups (p < 0.05). For age, only an influence was found within the TD group (p < 0.01); sex did not show to affect the outcomes (p = n.s.).

SIGNIFICANCE

An objective tool for quantitative measurement of postural control in childhood is needed. Our proposed VRRS tool could support the traditional assessment tests, highlighting differences between typical and atypical development.

The Experience of Caregivers Following a Moderate to Severe Traumatic Brain Injury Requiring ICU Admission

OBJECTIVES

Survivors of moderate and severe traumatic brain injury (TBI) require substantial care, much of which is ultimately provided by friends and family. We sought to describe the unmet needs of informal caregivers.

DESIGN

Qualitative, semistructured interviews with informal caregivers of moderate and severe TBI survivors were conducted 72 hours, 1 month, 3 months, and 6 months after injury.

SETTING

Intensive care unit of a level 1 trauma center.

PARTICIPANTS

Informal caregivers were friends or family who planned to provide care for the patient. Patients were 18 years or older with a moderate to severe TBI, and not expected to imminently die of their injuries.

MEASUREMENTS AND MAIN RESULTS

Eighteen patient-caregiver dyads were enrolled. Fifty-three interviews with caregivers were completed and analyzed over the course of 6 months. Three themes were identified in the qualitative analysis: caregiver burden, caregiver health-related quality of life, and caregiver needs for information and support.

CONCLUSIONS

This study provides new information about the experience of informal caregivers during the 6 months after their friend or family member survived a moderate to severe TBI. Interventions to promote caregiving may be a substantial opportunity to improve patient-centered outcomes following TBI.

Virtual reality or isokinetic training; its effect on pain, kinesiophobia and serum stress hormones in chronic low back pain: A randomized controlled trial

BACKGROUND

Evidence on the latest technologies in rehabilitation for reducing pain and altering serum stress hormones in low back pain (LBP) was lacking.

OBJECTIVE

To find the clinical and hormonal effects of virtual reality training (VRT) and isokinetic training (IKT) in chronic LBP patients.

METHODS

Through the simple random sampling method, 60 university football players with chronic LBP were allocated into three groups: NVRT= 20, NIKT= 20 and NCONTROL= 20. The three groups underwent different exercises for 4 weeks. Clinical (pain intensity and kinesiophobia) and hormonal (glucose, insulin, HOMA-IR, growth hormone, prolactin, ACTH and cortisol) values were measured at baseline, after 4 weeks and 6 months.

RESULTS

Four weeks following training, the VRT and IKT groups showed significant changes in pain intensity and kinesiophobia in comparison to the control group (p< 0.05). Hormonal measures also showed significant improvement in the VRT group in comparison to the other two groups (p< 0.05).

CONCLUSION

Training through virtual reality and isokinetic exercise is an effective approach in terms of pain and kinesiophobia. In terms of hormonal analysis, virtual reality shows slightly more improvements than isokinetic training in subjects with chronic LBP.

The Use of Home-Based Nonimmersive Virtual Reality to Encourage Physical and Cognitive Exercise in People With Mild Cognitive Impairment: A Feasibility Study

Individuals with mild cognitive impairment are at risk of cognitive and physical decline. Virtual reality (VR) exercise may provide beneficial physical and cognitive exercise. The objectives of this study were to assess the feasibility and safety of home-based VR exercise and to provide pilot data for physical and cognitive efficacy. Eleven individuals with mild cognitive impairment (seven males/four females, average 78 years old, and average 3 years since diagnosis) performed a 30-min home-based VR exercise program 5 days a week for 6 weeks. The VR platform was successfully installed in participants' homes, and all participants were able to learn the VR program and progress. Participants completed 99% of the prescribed exercise. There were no major adverse events. Most participants enjoyed the VR program and reported physical benefits; fewer reported cognitive benefits. No physical or cognitive outcome measures showed change after 6 weeks. Home-based VR exercise is safe and feasible in individuals with mild cognitive impairment.

Recommendations for the Design and Implementation of Virtual Reality for Acquired Brain Injury Rehabilitation: Systematic Review

BACKGROUND

Virtual reality (VR) is increasingly being used for the assessment and treatment of impairments arising from acquired brain injuries (ABIs) due to perceived benefits over traditional methods. However, no tailored options exist for the design and implementation of VR for ABI rehabilitation and, more specifically, traumatic brain injury (TBI) rehabilitation. In addition, the evidence base lacks systematic reviews of immersive VR use for TBI rehabilitation. Recommendations for this population are important because of the many complex and diverse impairments that individuals can experience.

OBJECTIVE

This study aims to conduct a two-part systematic review to identify and synthesize existing recommendations for designing and implementing therapeutic VR for ABI rehabilitation, including TBI, and to identify current evidence for using immersive VR for TBI assessment and treatment and to map the degree to which this literature includes recommendations for VR design and implementation.

METHODS

This review was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive search of 11 databases and gray literature was conducted in August 2019 and repeated in June 2020. Studies were included if they met relevant search terms, were peer-reviewed, were written in English, and were published between 2009 and 2020. Studies were reviewed to determine the level of evidence and methodological quality. For the first part, qualitative data were synthesized and categorized via meta-synthesis. For the second part, findings were analyzed and synthesized descriptively owing to the heterogeneity of data extracted from the included studies.

RESULTS

In the first part, a total of 14 papers met the inclusion criteria. Recommendations for VR design and implementation were not specific to TBI but rather to stroke or ABI rehabilitation more broadly. The synthesis and analysis of data resulted in three key phases and nine categories of recommendations for designing and implementing VR for ABI rehabilitation. In the second part, 5 studies met the inclusion criteria. A total of 2 studies reported on VR for assessment and three for treatment. Studies were varied in terms of therapeutic targets, VR tasks, and outcome measures. VR was used to assess or treat impairments in cognition, balance, and anxiety, with positive outcomes. However, the levels of evidence, methodological quality, and inclusion of recommendations for VR design and implementation were poor.

CONCLUSIONS

There is limited research on the use of immersive VR for TBI rehabilitation. Few studies have been conducted, and there is limited inclusion of recommendations for therapeutic VR design and implementation. Future research in ABI rehabilitation should consider a stepwise approach to VR development, from early co-design studies with end users to larger controlled trials. A list of recommendations is offered to provide guidance and a more consistent model to advance clinical research in this area.

Effects of Kinect Video Game Training on Lower Extremity Motor Function, Balance, and Gait in Adolescents with Spastic Diplegia Cerebral Palsy: A Pilot Randomized Controlled Trial

The Kinect video game (KVG) has received attention as an intervention method for cerebral palsy (CP). However, evidence remains limited.

PURPOSE

To investigate the effects of training using Xbox Kinect on lower extremity motor function, balance, and gait in adolescents with spastic diplegia CP.

METHODS

This study was a pilot randomized controlled trial. Ten participants were randomly allocated to either the KVG training group (n = 5) or the conventional training (CT) group (n = 5). The Selective Control Assessment of the Lower Extremity (SCALE) tool, Pediatric Balance Scale (PBS), and GAITRite were used for the outcome measurements.

RESULTS

In the comparison between the groups, the KVG group showed significant improvements in all the items in the SCALE (except for right hip abduction) and PBS score as compared with the CT group.

CONCLUSIONS

KVG training might be an effective intervention for the rehabilitation of adolescents with spastic diplegia CP.

Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy

More innovative technologies are used worldwide in patient's rehabilitation after stroke, as it represents a significant cause of disability. The majority of the studies use a single type of therapy in therapeutic protocols. We aimed to identify if the association of virtual reality (VR) therapy and mirror therapy (MT) exercises have better outcomes in lower extremity rehabilitation in post-stroke patients compared to standard physiotherapy. Fifty-nine inpatients from 76 initially identified were included in the research. One experimental group (n = 31) received VR therapy and MT, while the control group (n = 28) received standard physiotherapy. Each group performed seventy minutes of therapy per day for ten days. Statistical analysis was performed with nonparametric tests. Wilcoxon Signed-Rank test showed that both groups registered significant differences between pre-and post-therapy clinical status for the range of motion and muscle strength (p < 0.001 and Cohen's d between 0.324 and 0.645). Motor Fugl Meyer Lower Extremity Assessment also suggested significant differences pre-and post-therapy for both groups (p < 0.05 and Cohen's d 0.254 for the control group and 0.685 for the experimental group). Mann-Whitney results suggested that VR and MT as a therapeutic intervention have better outcomes than standard physiotherapy in range of motion (p < 0.05, Cohen's d 0.693), muscle strength (p < 0.05, Cohen's d 0.924), lower extremity functionality (p < 0.05, Cohen's d 0.984) and postural balance (p < 0.05, Cohen's d 0.936). Our research suggests that VR therapy associated with MT may successfully substitute classic physiotherapy in lower extremity rehabilitation after stroke.

Short-Term Psychological and Hormonal Effects of Virtual Reality Training on Chronic Low Back Pain in Soccer Players

OBJECTIVE

To find the short-term psychological and hormonal effects of virtual reality training on chronic low back pain in American soccer players.

DESIGN, SETTING, PARTICIPANTS

The 3-block random sampling method was used on 54 university American soccer players with chronic low back pain, and they were allocated into 3 groups: virtual reality training (VRT; n = 18), combined physical rehabilitation (n = 18), and control (n = 18) groups at University Hospital. They underwent different balance training exercises for 4 weeks. The participants and the therapist who is assessing the outcomes were blinded. Psychological (pain intensity and kinesiophobia) and hormonal (glucose, insulin, Homeostatic Model Assessment of Insulin Resistance, growth hormone, prolactin, adrenocorticotropic hormone, and cortisol) values were measured at baseline, after 4 weeks, and after 6 months.

RESULTS

The baseline demographic, psychological, and hormonal data between the VRT, combined physical rehabilitation, and control groups show no statistical difference (P ≥ .05). Four weeks following training, the VRT group shows more significant changes in pain intensity and kinesiophobia than the combined physical rehabilitation and control groups (P < .001), and the improvement was noted in the 6-month follow-up. All the hormonal variables (glucose, insulin, growth hormone, prolactin, adrenocorticotropic hormone, and cortisol) show significant changes at 4-week training (P < .001), except for the Homeostatic Model Assessment of Insulin Resistance (P = .075) between the 3 groups. At 6-month follow-up glucose, prolactin, adrenocorticotropic hormone, and cortisol show more significant difference in the VRT group than the other 2 groups (P < .001). At the same time, insulin (P = .694), Homeostatic Model Assessment of Insulin Resistance (P = .272), and growth hormone (P = .145) failed to show significant changes between the groups.

CONCLUSION

Training through virtual reality is an effective treatment program when compared with conventional exercise training programs from a psychological and hormonal analysis perspective in American soccer players with chronic low back pain.

Kinematic Gait Adjustments to Virtual Environments on Different Surface Conditions: Do Treadmill and Over-Ground Walking Exhibit Different Adaptations to Passive Virtual Immersion?

Background

The aim of this study was to examine the kinematic gait adjustments performed in response to passive and photorealistic virtual reality environment (VRE) demands during over-ground and treadmill walking conditions and determine whether the surface presentation order affects the gait adjustments in response to different VREs.

Methods

Twenty young participants divided into two groups performed two virtual reality (VR) walking protocols which included two different VREs (snowy and crowded conditions). Group A performed the VR over-ground protocol (four natural walking (NW), seven VR snowy, and seven VR crowded trials) followed by the VR treadmill protocol (four NW, one VR snowy, and one VR crowded trials); Group B performed the VR treadmill protocol (four NW, seven VR snowy, and seven VR crowded trials) followed by the VR over-ground protocol (four NW, one VR snowy, and one VR crowded trials). Center of mass (COM) excursion angles and mediolateral (ML) COM excursions were analyzed and used as outcome measures.

Results

Group A showed higher COM excursion angles and ML-COM excursion on over-ground VR trials compared to NW trials (p < 0.05), while Group B only showed kinematic changes for the crowded VRE compared to NW trials during the treadmill walking protocol (p < 0.05). Post over-ground exposure, Group A showed greater COM excursion angle and ML-COM excursions on VR trials compared to NW trials during the treadmill walking protocol (p < 0.05). Post treadmill exposure, Group B only showed higher COM excursion angles for the snowy VRE compared to NW trials during the over-ground walking protocol (p < 0.01).

Conclusion

Results showed that higher kinematic gait adjustments in response to VRE demands were observed during over-ground walking. Additionally, higher sensorimotor responses to VRE demands were observed when the VR protocol was first performed on the over-ground surface and followed by the treadmill walking condition (Group A) compared to the opposite (Group B).

Motor adaptation to real-life external environments using immersive virtual reality: A pilot study

INTRODUCTION

Virtual reality (VR) has been described as an emerging therapeutic strategy to promote motor adaptation in different populations. The aim of this study was to investigate the effect of virtual environment demands, provided by an immersive VR system, on kinematic and spatio-temporal gait parameters in healthy young participants.

METHODS

Fifteen healthy young participants participated in this experimental study performing, in sequence, a baseline natural walking (NW) block, two different virtual environment walking blocks (snowy and crowded conditions), and a mixed walking block (including NW, snowy, and crowded conditions). Participants' Center-of-Mass (COM) excursion angle, medio-lateral (ML) COM excursion, step length, and walking speed were analyzed for each trial.

RESULTS

COM excursion angle and ML-COM excursion increased significantly during the first snowy and crowded VR trials compared to NW trials, while walking speed and step length decreased only for the snowy conditions. COM excursion angle and ML-COM excursion increased significantly from the first to the fourth VR snowy trial and decreased from the first to the fourth VR crowded trial. Participants retained the acquired motor adaptations even after the mixed block.

CONCLUSION

This study showed that kinematic and spatio-temporal gait parameters of young participants changed according to the virtual environment demands provided for each virtual scenario. In addition, all participants showed a consistent gait adaptation process to each virtual environment across the VR trials. The present findings highlight the impact of VR for gait adaptation, suggesting that VR training could modify motor behavior and enhance the motor adaptation process in healthy young participants.

Acceptance of Rehabilitation Technology in Adults With Moderate to Severe Traumatic Brain Injury, Their Caregivers, and Healthcare Professionals: A Systematic Review

BACKGROUND

Moderate to severe traumatic brain injuries (TBIs) commonly result in persistent physical, cognitive, and/or emotional deficits that require long-term rehabilitation. Technology-enabled rehabilitation provides an innovative alternative to traditional intervention models. End-user acceptance of these interventions, however, is a critical factor in determining the effective implementation and acceptance of these technologies.

OBJECTIVE

To systematically review the literature to identify methods and measures used to evaluate user acceptance relating to rehabilitation technologies for adults with moderate to severe TBI, their caregivers, and healthcare professionals.

METHODS

Six key databases including Medline, Embase, CINAHL, Cochrane, Scopus, and Web of Science were searched using the relevant search terms.

RESULTS

From a yield of 2059 studies, 13 studies met the eligibility criteria. The review revealed limited research that formally evaluated user acceptance in relation to rehabilitation technologies designed for adults with TBI. Furthermore, where such evaluations were conducted, comprehensive research designs incorporating theoretical frameworks of technology acceptance were sparse. Importantly, a range of technologies and recommendations that positively influenced user acceptance were identified. Future directions for research in this area include the use of theory-driven research designs to enhance our understanding of technology acceptance, to support the development of rehabilitation technologies that maximize functional outcomes for individuals with TBI.

Comparative effects of virtual reality training and sensory motor training on bone morphogenic proteins and inflammatory biomarkers in post-traumatic osteoarthritis

The objective of this study is to compare the effects of virtual reality training (VRT) and sensory-motor training (SMT) in bone morphogenetic proteins (BMP) and inflammatory biomarkers expression in post-traumatic osteoarthritis (PTOA) after the anterior cruciate ligament injury. Through a simple random sampling method, 60 eligible participants were allocated into VRT (n = 20), SMT (n = 20), and control groups (n = 20). They underwent training programs for 4 weeks. Clinical (pain intensity and functional disability) and biochemical (bone morphogenic proteins and inflammatory biomarkers) values were measured at baseline, after 4 weeks, 8 weeks and 3 months follow up. Four weeks following training, the VRT group shows more significant changes in pain intensity and functional disability than SMT and control groups (P < 0.001). Bone morphogenic protein (BMP) measures such as BMP 2, 4, 6, and 7 don’t show any significant changes between the groups. But at the same time, the VRT group shows positive improvement in inflammatory biomarkers (CRP, TNF-α, IL-2, IL-4, IL-6) analysis than the other two groups (P < 0.001). Our study suggests that including virtual reality training in PTOA shows beneficial changes in pain, functional disability, and modification of inflammatory biomarkers than sensory-motor training, but at the same time it shows a negligible effect on bone morphogenic proteins.

Exploring perspectives from stroke survivors, carers and clinicians on virtual reality as a precursor to using telerehabilitation for spatial neglect post-stroke

Spatial neglect is a common and severe cognitive consequence of stroke, yet there is currently no effective rehabilitation tool. Virtual Reality (VR) telerehabilitation tools have the potential to provide multisensory and enjoyable therapies and remotely monitor adherence without the presence of a therapist at all times. Researchers and industry need to better understand end-user perspectives about these technologies to ensure these are acceptable and, ultimately, optimize adherence and efficacy. This study aims to explore end-user perspectives on the use of self-administered VR for spatial neglect in a university environment to identify barriers and facilitators prior to extending its use remotely as a telerehabilitation tool. We used a mixed-method design including focus groups, self-administered questionnaires and interviews with stroke survivors (N = 7), their carers (N = 3) and stroke clinicians (N = 6). End-user perspectives identified clarity of instructions, equipment (cost, available resources) and for some, level of experience with technology as barriers of use. Perceived facilitators were performance feedback, engagement and enjoyment, and psychological benefits associated with self-administered VR telerehabilitation. Overall, end-users were positive and interested in using VR telerehabilitation for spatial neglect. These perspectives enabled us to produce practical recommendations to inform development, enhance engagement and uptake of VR telerehabilitation and inform future studies.

Effects of physical therapy interventions on balance ability in people with traumatic brain injury: A systematic review

BACKGROUND

Balance deficits are common impairments in individuals with post-traumatic brain injury (TBI). Balance deficits can restrict the activities of daily living and productive participation in social life. To date, no systematic reviews have examined the impact of physical therapy intervention on balance post-TBI.

OBJECTIVE

To examine the effects of physical therapy interventions on balance impairments in individuals with TBI.

METHODS

We systematically searched in PubMed, EMBASE, Scopus, PEDro, MEDLINE, REHABDATA, and Web of Science for randomized controlled trials (RCTs), clinical control trials, and pilot studies that examined the effects of physical therapy interventions on balance deficits in individuals post-TBI. The methodological quality was estimated using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Eight studies published from 2003 to 2019 were included in this study. A total of 259 TBI participants post-TBI were included in this review, 71 (27.41%) of which were females. The methodological quality of the selected studies ranged from low to high. There were no significant differences between experimental interventions, virtual reality (VR), vestibular rehabilitation therapy (VRT), control group interventions, and other traditional physical therapy interventions.

CONCLUSIONS

The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited. Further randomized controlled trials are strongly warranted to understand the role of physical therapy in patients with TBI who complain about balance deficits.

A Prospective, Multicenter Study to Assess the Safety and Efficacy of Translingual Neurostimulation Plus Physical Therapy for the Treatment of a Chronic Balance Deficit Due to Mild‐to‐Moderate Traumatic Brain Injury

Objectives

Materials and Methods

Results

Conclusions

Sitting Balance Exercise Performed Using Virtual Reality Training on a Stroke Rehabilitation Inpatient Service: A Randomized Controlled Study

BACKGROUND

Virtual reality training (VRT) is engaging and may enhance rehabilitation intensity. Only one previous study has looked at its use to improve sitting balance after stroke.

OBJECTIVE

To determine if supplemental sitting balance exercises, administered via VRT, improve control of sitting balance and upper extremity function in stroke rehabilitation inpatients.

DESIGN

Assessor-blinded, placebo-controlled randomized controlled trial.

SETTING

Stroke inpatient rehabilitation unit.

PARTICIPANTS

Seventy-six participants (out of 130 approached) with subacute stroke who could not stand independently were randomized to experimental and control groups. Sixty-nine completed the study.

INTERVENTIONS

The experimental group did VRT that required leaning and reaching, whereas the control group had their trunk restrained and performed VRT that involved only small upper extremity movements to minimize trunk movement. Both groups performed 10-12 sessions of 30-45 minutes. Participants were assessed pre, post, and 1 month after the sessions by a blinded examiner.

OUTCOME MEASURES

Function in Sitting Test (FIST, primary outcome measure); Ottawa Sitting Scale; Reaching Performance Scale; Wolf Motor Function Test (WMFT).

RESULTS

Thirty-three participants completed the experimental intervention and 36 the control. Pre/post differences for FIST were 3.4 (confidence interval [CI] 0.5;6.3) for the experimental group and 5.3 (2.9;7.7) for the control group. There was a significant improvement over time (adjusted for multiple comparisons, P < .006) on most outcome measures except the WMFT Performance Time Scale (control group; P = .007) and grip strength (P = .008); there were no differences between groups (P > .006).

CONCLUSIONS

Siting balance outcomes were similar for both groups; therefore, this study does not support the use of sitting balance exercises provided via VRT for the rehabilitation of sitting balance after stroke. However, because it is only the second study to investigate VRT for sitting balance and upper extremity function, more research, using more challenging exercises and a greater treatment intensity, is required before definitive conclusions are made.

Effects of exergames on trunk balance control in paraplegic patients

Abstract Introduction: Due to motivation and immediate feedback during activities, exergame-based physical therapy may improve trunk balance and functionality in individuals with spinal cord injury (SCI). Objective: evaluate the effects of exergames on the trunk control of paraplegics with spinal cord injury or meningomyelocele. Method: case series involving four paraplegic patients, with SCI or meningomyelocele. Participants underwent a rehabilitation protocol using the exergame Nintendo Wii®, attending one weekly session for 4 weeks. Patients were encouraged to perform trunk movements in the sitting position using the Swordplay and Canoeing games. Data were collected before and after the intervention by applying the functional reach test adapted for trunk control evaluation, and transfer time and propulsion tests for functional assessment. Results: The intervention increased trunk control in 75% of the patients, with improvement varying between 6.4 and 25%. In the propulsion test, the intervention led to a decrease in half of the patients. For the cadence variable, in the same test, there was a reduction in the number of propulsions in 75% of the cases. In the transfer test, the intervention led to reduced chair-to-bed transfer time in all patients. Conclusion: Rehabilitation of paraplegics with the use of exergames can be considered viable, innovative and effective. However, future research with greater methodological rigor should be conducted in order to analyze the clinical applicability of this approach.

Virtual reality and chronic low back pain

AIM

Chronic low back pain (CLBP) is a highly prevalent and significant cause of disability which is often resistant to pharmacological management. Virtual reality (VR) is an emerging technology with the potential to influence CLBP, and has been suggested as an alternative to opioids for pain management. VR is a goalfocused, computer-simulated reality allowing modification of the user's experience of their perceived world.

MATERIALS/METHODS

A narrative review of peer-reviewed literature using a systematic search strategy, and sole reviewer for data extraction.

CONCLUSIONS

VR has demonstrated effectiveness in reducing acute, experimental and chronic pain. This review describes the theoretical basis of the therapeutic effects of VR on CLBP via three distinct mechanisms: distraction, neuromodulation and graded exposure therapy. Furthermore, clinical application will be considered, including discussion of ethical issues associated with the technology.Implications for rehabilitationVirtual reality (VR) is suggested as an alternative for opioids in the management of acute and chronic pain.The therapeutic mechanisms of VR in chronic low back pain (CLBP) are equivocal but include distraction, neuromodulation of body perception and graded exposure therapy.VR may show greater efficacy in patients with CLBP with associated kinesiophobia.VR may show greater effect with increased immersion.

Translingual Neurostimulation for the Treatment of Chronic Symptoms Due to Mild-to-Moderate Traumatic Brain Injury

Objective

To compare the efficacy of high- and low-frequency noninvasive translingual neurostimulation (TLNS) plus targeted physical therapy (PT) for treating chronic balance and gait deficits due to mild-to-moderate traumatic brain injury (mmTBI).

Design

Participants were randomized 1:1 in a 26-week double-blind phase 1/2 study (NCT02158494) with 3 consecutive treatment stages: in-clinic, at-home, and no treatment. Arms were high-frequency pulse (HFP) and low-frequency pulse (LFP) TLNS.

Setting

TLNS plus PT training was initiated in-clinic and then continued at home.

Participants

Participants (N=44; 18-65y) from across the United States were randomized into the HFP and LFP (each plus PT) arms. Forty-three participants (28 women, 15 men) completed at least 1 stage of the study. Enrollment requirements included an mmTBI ≥1 year prior to screening, balance disorder due to mmTBI, a plateau in recovery with current PT, and a Sensory Organization Test (SOT) score ≥16 points below normal.

Interventions

Participants received TLNS (HFP or LFP) plus PT for a total of 14 weeks (2 in-clinic and 12 at home), twice daily, followed by 12 weeks without treatment.

Main Outcome Measures

The primary endpoint was change in SOT composite score from baseline to week 14. Secondary variables (eg, Dynamic Gait Index [DGI], 6-minute walk test [6MWT]) were also collected.

Results

Both arms had a significant (P<.0001) improvement in SOT scores from baseline at weeks 2, 5, 14 (primary endpoint), and 26. DGI scores had significant improvement (P<.001-.01) from baseline at the same test points; 6MWT evaluations after 2 weeks were significant. The SOT, DGI, and 6MWT scores did not significantly differ between arms at any test point. There were no treatment-related serious adverse events.

Conclusions

Both the HFP+PT and LFP+PT groups had significantly improved balance scores, and outcomes were sustained for 12 weeks after discontinuing TLNS treatment. Results between arms did not significantly differ from each other. Whether the 2 dosages are equally effective or whether improvements are because of provision of PT cannot be conclusively established at this time.

Results From a Randomized Controlled Trial to Address Balance Deficits After Traumatic Brain Injury

OBJECTIVE

To evaluate the efficacy of an in-home 12-week physical therapy (PT) intervention that utilized a virtual reality (VR) gaming system to improve balance in individuals with traumatic brain injury (TBI).

SETTING

Home-based exercise program (HEP).

PARTICIPANTS

Individuals (N=63; traditional HEP n=32; VR n=31) at least 1 year post-TBI, ambulating independently within the home, not currently receiving PT services.

MAIN OUTCOME MEASURES

Primary: Community Balance and Mobility Scale (CB&M); Secondary: Balance Evaluation Systems Test (BESTest), Activities-Specific Balance Confidence Scale (ABC), Participation Assessment with Recombined Tools-Objective (PART-O).

RESULTS

No significant between-group differences were observed in the CB&M over the study duration (P=.9983) for individuals who received VR compared to those who received a HEP to address balance deficits after chronic TBI nor in any of the secondary outcomes: BESTest (P=.8822); ABC (P=.4343) and PART-O (P=.8822). However, both groups demonstrated significant improvements in CB&M and BESTest from baseline to 6, 12, and at 12 weeks follow-up (all P's <.001). Regardless of treatment group, 52% of participants met or exceeded the minimal detectable change of 8 points on the CB&M at 24 weeks and 38% met or exceeded the minimal detectable change of 7.81 points on the BESTest.

CONCLUSION

This study did not find that VR training was more beneficial than a traditional HEP for improving balance. However, individuals with chronic TBI in both treatment groups demonstrated improvements in balance in response to these interventions which were completed independently in the home environment.

A Randomized Feasibility Trial of a Novel, Integrative, and Intensive Virtual Rehabilitation Program for Service Members Post-Acquired Brain Injury

Introduction

Acquired Brain Injury, whether resulting from Traumatic brain injury (TBI) or Cerebral Vascular Accident (CVA), represent major health concerns for the Department of Defense and the nation. TBI has been referred to as the “signature” injury of recent U.S. military conflicts in Iraq and Afghanistan – affecting approximately 380,000 service members from 2000 to 2017; whereas CVA has been estimated to effect 795,000 individuals each year in the United States. TBI and CVA often present with similar motor, cognitive, and emotional deficits; therefore the treatment interventions for both often overlap. The Defense Health Agency and Veterans Health Administration would benefit from enhanced rehabilitation solutions to treat deficits resulting from acquired brain injuries (ABI), including both TBI and CVA. The purpose of this study was to evaluate the feasibility of implementing a novel, integrative, and intensive virtual rehabilitation system for treating symptoms of ABI in an outpatient clinic. The secondary aim was to evaluate the system’s clinical effectiveness.

Materials and Methods

Military healthcare beneficiaries with ABI diagnoses completed a 6-week randomized feasibility study of the BrightBrainer Virtual Rehabilitation (BBVR) system in an outpatient military hospital clinic. Twenty-six candidates were screened, consented and randomized, 21 of whom completed the study. The BBVR system is an experimental adjunct ABI therapy program which utilizes virtual reality and repetitive bilateral upper extremity training. Four self-report questionnaires measured participant and provider acceptance of the system. Seven clinical outcomes included the Fugl-Meyer Assessment of Upper Extremity, Box and Blocks Test, Jebsen-Taylor Hand Function Test, Automated Neuropsychological Assessment Metrics, Neurobehavioral Symptom Inventory, Quick Inventory of Depressive Symptomatology-Self-Report, and Post Traumatic Stress Disorder Checklist- Civilian Version. The statistical analyses used bootstrapping, non-parametric statistics, and multilevel/hierarchical modeling as appropriate. This research was approved by the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences Institutional Review Boards.

Results

All of the participants and providers reported moderate to high levels of utility, ease of use and satisfaction with the BBVR system (x̄ = 73–86%). Adjunct therapy with the BBVR system trended towards statistical significance for the measure of cognitive function (ANAM [x̄ = −1.07, 95% CI −2.27 to 0.13, p = 0.074]); however, none of the other effects approached significance.

Conclusion

This research provides evidence for the feasibility of implementing the BBVR system into an outpatient military setting for treatment of ABI symptoms. It is believed these data justify conducting a larger, randomized trial of the clinical effectiveness of the BBVR system.

Centre of pressure displacements produced in sitting during virtual reality training in younger and older adults and patients who have had a stroke

Purpose: Poor sitting balance is common after stroke and makes leaning and reaching while sitting difficult and dangerous. Virtual reality training (VRT) uses computer hardware and software to track a person's movements and allow him or her to interact with a virtual environment. VRT games are available to train sitting balance after stroke; however, it is unknown how challenging they are. The objectives of this study were to characterize the centre of pressure displacements generated during the performance of VRT in stroke patients (ST) and compare their performance to that of young (YA) and older adults (OA).Materials and Methods: Eight ST participants who could stand for at least four minutes were recruited from an inpatient stroke rehabilitation unit for this cross-sectional, observational pilot study. Eight YA and eight OA were recruited from the community. Participants sat on a pressure mat and played 17 VRT game/difficulty combinations. The area, range and average velocity of centre of pressure displacement were determined for each game/difficulty.Results: Virtually manoeuvring a motorcycle around barriers and leaning to move a ball down a maze produced the greatest displacement of the centre of pressure, particularly in the mediolateral direction. OA moved further and faster in the mediolateral direction than YA. ST's performance was more variable.Conclusions: Some VRT games were more likely to push participants to challenge their limits of stability. Others required less displacement but more trunk stability. These results can guide which VRT games are used for the rehabilitation of sitting balance after stroke.Implications for rehabilitationSome virtual reality training games produce greater displacements of the centre of pressure in sitting than others, suggesting that careful matching between game challenge and desired therapeutic outcome is necessary when selecting games.Virtual reality training performed in sitting with feet on the floor challenges sitting balance in the frontal plane more so than in the sagittal plane.Older adults tend to lean more than younger adults while individuals with stroke move more or less than others, depending on the game.

Home-based virtual reality training after discharge from hospital-based stroke rehabilitation: a parallel randomized feasibility trial

Background

Virtual reality training (VRT) uses computer software to track a user’s movements and allow him or her to interact with a game presented on a television screen. VRT is increasingly being used for the rehabilitation of arm function, balance and walking after stroke. Patients often require ongoing therapy post discharge from inpatient rehabilitation. Outpatient therapy may be limited or inaccessible due to waiting lists, transportation issues, distance etc.; therefore, home-based VRT could provide the required therapy in a more convenient and accessible setting. The objectives of this parallel randomized feasibility trial are to determine (1) the feasibility of using VRT in the home post stroke and (2) the feasibility of a battery of quantitative and qualitative outcome measures of stroke recovery.

Methods

Forty patients who can stand for at least 2 min and are soon to be discharged from inpatient or outpatient rehabilitation post stroke are being recruited in Ottawa, Canada and being randomized to control and experimental groups. Participants in the experimental group use home-based VRT to do rehabilitative exercises for standing balance, stepping, reaching, strengthening and gentle aerobic fitness. Control group participants use an iPad with apps selected to rehabilitate cognition, hand fine motor skills and visual tracking/scanning. Both groups are instructed to perform 30 min of exercise 5 days a week for 6 weeks. VRT intensity and difficulty are monitored and adjusted remotely. Weekly telephone contact is made with all participants. Ability to recruit participants, ability to handle the technology and learn the activities, compliance, safety, enjoyment, perceived efficacy and cost of program delivery will be assessed. A battery of assessments of standing balance, gait and community integration will be assessed for feasibility of completion within this population and potential for improvement following the intervention. Effect sizes will be calculated.

Discussion

The results of this study will be used to support the creation of a definitive randomized controlled trial on the efficacy of home-based VRT for rehabilitation post stroke.

Trial Registration

ClinicalTrials.gov, NCT03261713. Registered on 21 August 2017. Registration amended on 1 June 2018 to decrease enrollment from 40 to 20 due to a cut in study funding and difficulty recruiting participants.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3438-9) contains supplementary material, which is available to authorized users.

Efficacy of virtual reality to reduce chronic low back pain: Proof-of-concept of a non-pharmacological approach on pain, quality of life, neuropsychological and functional outcome

Objectives

Chronic pain, such as low-back pain, can be a highly disabling condition degrading people’s quality of life (QoL). Not every patient responds to pharmacological therapies, thus alternative treatments have to be developed. The chronicity of pain can lead to a somatic dysperception, meaning a mismatch between patients’ own body perception and its actual physical state. Since clinical evaluation of pain relies on patients’ subjective reports, a body image disruption can be associated with an incorrect pain rating inducing incorrect treatment and a possible risk of drug abuse. Our aim was to reduce chronic low-back pain through a multimodal neurorehabilitative strategy using innovative technologies to help patients regain a correct body image.

Methods

Twenty patients with chronic low-back pain were included. Before and after treatment, patients underwent: a neurological exam; a neuro-psychological evaluation testing cognitive functions (memory, attention, executive functions) and personality traits, QoL and mood; pain ratings; sensorimotor functional abilities’ testing. Patients underwent a 6 week-neurorehabilitative treatment (total 12 sessions) using virtual reality (VRRS system, Khymeia, Italy). Treatment consisted on teaching patients to execute correct movements with the painful body parts to regain a correct body image, based on the augmented multisensory feedback (auditory, visual) provided by the VRRS.

Results

Our data showed significant reductions in all pain rating scale scores (p<0.05); significant improvements of QoL in the domains of physical functioning, physical role functioning, bodily pain, vitality, and social role functioning; improvements in cognitive functions (p<0.05); improvements in functional scales (p<0.05) and mood (p = 0.04).

Conclusion

This non-pharmacological approach was able to act on the multi-dimensional aspects of pain and improved patients’ QoL, pain intensity, mood and patient’s functional abilities.

Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology

BACKGROUND

Traumatic brain injury (TBI) can causes numerous cognitive impairments usually in the aspects of problem-solving, executive function, memory, and attention. Several studies has suggested that rehabilitation treatment interventions can be effective in treating cognitive symptoms of brain injury. Virtual reality (VR) technology potential as a useful tool for the assessment and rehabilitation of cognitive processes.

OBJECTIVES

The aims of present systematic review are to examine effects of VR training intervention on cognitive function, and to identify effective VR treatment protocol in patients with TBI.

METHODS

PubMed, Scopus, PEDro, REHABDATA, EMBASE, web of science, and MEDLINE were searched for studies investigated effect of VR on cognitive functions post TBI. The methodological quality were evaluated using PEDro scale. The results of selected studies were summarized.

RESULTS

Nine studies were included in present study. Four were randomized clinical trials, case studies (n = 3), prospective study (n = 1), and pilot study (n = 1). The scores on the PEDro ranged from 0 to 7 with a mean score of 3. The results showed improvement in various cognitive function aspects such as; memory, executive function, and attention in patients with TBI after VR training.

CONCLUSION

Using different VR tools with following treatment protocol; 10-12 sessions, 20-40 min in duration with 2-4 sessions per week may improves cognitive function in patients with TBI. There was weak evidence for effects of VR training on attention post TBI.

Balance in chronic traumatic brain injury: correlations between clinical measures and a self-report measure

OBJECTIVE

To assess associations among commonly used self-report and clinical measures of balance in chronic TBI.

DESIGN

Cross-sectional analysis of balance in a convenience sample of individuals at least one year post TBI.

MAIN OUTCOME MEASURES

Activities-Specific Balance Confidence Scale (ABC) (self-reported balance impairment), Community Balance and Mobility Scale (CB&M) (clinical measure validated in TBI), and Balance Evaluation Systems Test (BESTest) (clinical measure not validated in TBI).

METHODS

Fifty-nine individuals (64% male, mean age 48.2 years) ambulating independently within the home participated in testing. Pearson correlation coefficients were used to quantify the direction and magnitude of the relationships among the three balance impairment measures.

RESULTS

A significant positive correlation was noted between the ABC and CB&M (r = 0.42, p = 0.0008), between the ABC and BESTest (r = 0.46, p = 0.0002), and between the CB&M and BESTest (r = 0.86, p < 0.0001).

CONCLUSIONS

This is the first study we are aware of in the chronic moderate to severe TBI population directly comparing patient's self-reported balance impairment with clinical measures. Positive correlations were found between the self-report measure and both clinical measures. Overall, individuals with chronic TBI tend to self-report less impaired balance than clinical measures indicate. These results provide preliminary evidence to support the need for validation of the BESTest in this population.

ABBREVIATIONS

ABC: Activities-specific balance confidence scale; BESTest: balance evaluation systems test; BOS: base of support; COM: center of mass; CB&M: community balance and mobility scale; CI: confidence interval; IQR: interquartile range; PTs: physical therapists; SD: standard deviation; SE: standard error; TBI: traumatic brain injury.

Is balance performance reduced after mild traumatic brain injury?: Interim analysis from chronic effects of neurotrauma consortium (CENC) multi-centre study

OBJECTIVES

Determine if mild traumatic brain injury (mTBI) history is associated with balance disturbances.

SETTING

Chronic Effects of Neurotrauma Consortium (CENC) centres.

PARTICIPANTS

The CENC multi-centre study enrols post-9/11 era Service Members and Veterans with combat exposure. This sample (n = 322) consisted of enrolees completing initial evaluation by September 2016 at the three sites conducting computerized dynamic post-urography (CDP) testing.

DESIGN

Observational study with cross-sectional analyses using structural equation modelling.

MAIN MEASURES

Comprehensive structured interviews were used to diagnose all lifetime mild traumatic brain injuries (mTBIs). The outcome, Sensory Organization Test (SOT), was measured on CDP dual-plate force platform. Other studied variables were measured by structured interviews, record review and questionnaires.

RESULTS

The overall positive/negative mTBI classification did not have a significant effect on the composite equilibrium score. However, the repetitive mTBI classification showed lower scores for participants with ≥ 3 mTBI versus 1-2 lifetime mTBIs. For repetitive mTBI, pain interference acted as a mediator for the indirect effect, and a direct effect was evident on some sensory condition equilibrium scores.

CONCLUSION

These findings show that repeated mTBI, partially mediated by pain, may lead to later balance disturbances among military combatants. Further study of CDP outcomes within this accruing cohort is warranted.

Systematic Review of Caregiver and Dyad Interventions After Adult Traumatic Brain Injury

OBJECTIVE

To describe and synthesize the literature on adult traumatic brain injury (TBI) family caregiver and dyad intervention. TBI is a common injury that has a significant long-term impact, and is sometimes even characterized as a chronic condition. Informal (ie, unpaid) family caregivers of adults with TBI experience high rates of burnout, depression, fatigue, anxiety, lower subjective well-being, and poorer levels of physical health compared to noncaregivers. This study addresses the critical gap in the understanding of interventions designed to address the impact of TBI on adult patients and their family caregivers.

DATA SOURCES

PubMed and MEDLINE.

STUDY SELECTION

Studies selected for review had to be written in English and be quasi-experimental or experimental in design, report on TBI caregivers, survivors with heavy involvement of caregivers, or caregiver dyads, involve moderate and severe TBI, and describe an intervention implemented during some portion of the TBI care continuum.

DATA EXTRACTION

The search identified 2171 articles, of which 14 met our criteria for inclusion. Of the identified studies, 10 were randomized clinical trials and 4 were nonrandomized quasi-experimental studies. A secondary search to describe studies that included individuals with other forms of acquired brain injury in addition to TBI resulted in 852 additional titles, of which 5 met our inclusion criteria.

DATA SYNTHESIS

Interventions that targeted the caregiver primarily were more likely to provide benefit than those that targeted caregiver/survivor dyad or the survivor only. Many of the studies were limited by poor fidelity, low sample sizes, and high risk for bias based on randomization techniques.

CONCLUSIONS

Future studies of TBI caregivers should enroll a more generalizable number of participants and ensure adequate fidelity to properly compare interventions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

PROSPERO CRD42016042051.

The effect of parallax on eye fixation parameter in projection-based stereoscopic displays

The promising technology of stereoscopic displays is interesting to explore because 3D virtual applications are widely known. Thus, this study investigated the effect of parallax on eye fixation in stereoscopic displays. The experiment was conducted in three different levels of parallax, in which virtual balls were projected at the screen, at 20 cm and 50 cm in front the screen. The two important findings of this study are that parallax has significant effects on fixation duration, time to first fixation, number of fixations, and accuracy. The participant had more accurate fixations, fewer fixations, shorter fixation durations, and shorter times to first fixation when the virtual ball was projected at the screen than when it was projected at the other two levels of parallax.

Immersion of virtual reality for rehabilitation - Review

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

A video-game group intervention: Experiences and perceptions of adults with chronic stroke and their therapists: Intervention de groupe à l'aide de jeux vidéo : Expériences et perceptions d'adultes en phase chronique d'un accident vasculaire cérébral et de leurs ergothérapeutes

BACKGROUND

Ongoing physical activity is important for maintaining the functional level of individuals with chronic stroke. Video games in a group setting might be a cost-effective way for providing mobility and preventing physical inactivity.

PURPOSE

This study explores the experiences and perceptions of individuals with chronic stroke who participated in a novel community-based video-game group intervention and their therapists.

METHOD

A qualitative study, nested in a randomized controlled trial, was conducted using semistructured interviews with eight individuals with chronic stroke (four men and four women) ages 29 to 69 and a focus group of their three occupational therapists, following a video-game intervention. Data were analyzed using content analysis.

FINDINGS

Three main categories were identified by the study participants: (a) using video games, (b) the group/team experience, and (c) intervention outcomes/evolving understandings following the intervention.

IMPLICATIONS

Playing video games was perceived not as treatment but as a motivating tool to facilitate whole-body movement. Therefore, this intervention might be suitable to be used in the community for ongoing intervention.

The effects of semi-immersive virtual reality therapy on standing balance and upright mobility function in individuals with chronic incomplete spinal cord injury: A preliminary study

BACKGROUND

Individuals with chronic incomplete spinal cord injury (iSCI) commonly face persistent balance or mobility impairments. Virtual reality (VR) therapy is a useful rehabilitation approach; however, little is known about its effects in individuals with chronic iSCI.

OBJECTIVE

To investigate the effects of semi-immersive VR therapy on standing balance and upright mobility function in individuals with chronic iSCI.

METHODS

Ten subjects with chronic iSCI underwent VR therapy 30 minutes a day, 3 days a week, for 6 weeks. Limit of stability (LOS) and the Berg Balance Scale (BBS) were used to evaluate standing balance function. The Timed Up & Go (TUG) test, Activities-specific Balance Confidence (ABS) Scale, and Walking Index for Spinal Cord Injury-II (WISCI-II) were used to measure the subject's upright mobility function. Outcomes were assessed and recorded pre- and post-intervention.

RESULTS

After semi-immersive VR therapy, LOS and BBS scores were significantly increased. In addition, the TUG test results increased significantly over time, while ABC scale scores and WSCI-II levels improved significantly.

CONCLUSION

This study is the first to assess the effects of semi-immersive VR therapy for patients with chronic iSCI and limited functional abilities. These results indicated that semi-immersive VR therapy has a positive effect and is a useful intervention for standing balance and upright mobility function in patients with chronic iSCI.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Reported use of technology in stroke rehabilitation by physical and occupational therapists

PURPOSE

With the patient care experience being a healthcare priority, it is concerning that patients with stroke reported boredom and a desire for greater fostering of autonomy, when evaluating their rehabilitation experience. Technology has the potential to reduce these shortcomings by engaging patients through entertainment and objective feedback. Providing objective feedback has resulted in improved outcomes and may assist the patient in learning how to self-manage rehabilitation. Our goal was to examine the extent to which physical and occupational therapists use technology in clinical stroke rehabilitation home exercise programs.

MATERIALS AND METHODS

Surveys were sent via mail, email and online postings to over 500 therapists, 107 responded.

RESULTS

Conventional equipment such as stopwatches are more frequently used compared to newer technology like Wii and Kinect games. Still, less than 25% of therapists' report using a stopwatch five or more times per week. Notably, feedback to patients is based upon objective data less than 50% of the time by most therapists. At the end of clinical rehabilitation, patients typically receive a written home exercise program and non-technological equipment, like theraband and/or theraputty to continue rehabilitation efforts independently.

CONCLUSIONS

The use of technology is not pervasive in the continuum of stroke rehabilitation. Implications for Rehabilitation The patient care experience is a priority in healthcare, so when patients report feeling bored and desiring greater fostering of autonomy in stroke rehabilitation, it is troubling. Research examining the use of technology has shown positive results for improving motor performance and engaging patients through entertainment and use of objective feedback. Physical and occupational therapists do not widely use technology in stroke rehabilitation. Therapists should consider using technology in stroke rehabilitation to better meet the needs of the patient.

The effects of video game therapy on balance and attention in chronic ambulatory traumatic brain injury: an exploratory study

Background

Patients with traumatic brain injury often have balance and attentive disorders. Video game therapy (VGT) has been proposed as a new intervention to improve mobility and attention through a reward-learning approach. In this pilot randomized, controlled trial, we tested the effects of VGT, compared with a balance platform therapy (BPT), on balance, mobility and selective attention in chronic traumatic brain injury patients.

Methods

We enrolled chronic traumatic brain injury patients (n = 21) that randomly received VGT or BPT for 3 sessions per week for 6 weeks. The clinical outcome measures included: i) the Community Balance & Mobility Scale (CB&M); ii) the Unified Balance Scale (UBS); iii) the Timed Up and Go test (TUG); iv) static balance and v) selective visual attention evaluation (Go/Nogo task).

Results

Both groups improved in CB&M scores, but only the VGT group increased on the UBS and TUG with a between-group significance (p < 0.05). Selective attention improved significantly in the VGT group (p < 0.01).

Conclusions

Video game therapy is an option for the management of chronic traumatic brain injury patients to ameliorate balance and attention deficits.

Trial registration

NCT01883830, April 5 2013.

Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review

BACKGROUND

Virtual reality (VR) based applications play an increasing role in motor rehabilitation. They provide an interactive and individualized environment in addition to increased motivation during motor tasks as well as facilitating motor learning through multimodal sensory information. Several previous studies have shown positive effect of VR-based treatments for lower extremity motor rehabilitation in neurological conditions, but the characteristics of these VR applications have not been systematically investigated. The visual information on the user's movement in the virtual environment, also called movement visualisation (MV), is a key element of VR-based rehabilitation interventions. The present review proposes categorization of Movement Visualisations of VR-based rehabilitation therapy for neurological conditions and also summarises current research in lower limb application.

METHODS

A systematic search of literature on VR-based intervention for gait and balance rehabilitation in neurological conditions was performed in the databases namely; MEDLINE (Ovid), AMED, EMBASE, CINAHL, and PsycInfo. Studies using non-virtual environments or applications to improve cognitive function, activities of daily living, or psychotherapy were excluded. The VR interventions of the included studies were analysed on their MV.

RESULTS

In total 43 publications were selected based on the inclusion criteria. Seven distinct MV groups could be differentiated: indirect MV (N = 13), abstract MV (N = 11), augmented reality MV (N = 9), avatar MV (N = 5), tracking MV (N = 4), combined MV (N = 1), and no MV (N = 2). In two included articles the visualisation conditions included different MV groups within the same study. Additionally, differences in motor performance could not be analysed because of the differences in the study design. Three studies investigated different visualisations within the same MV group and hence limited information can be extracted from one study.

CONCLUSIONS

The review demonstrates that individuals' movements during VR-based motor training can be displayed in different ways. Future studies are necessary to fundamentally explore the nature of this VR information and its effect on motor outcome.