The use of virtual reality for balance among individuals with chronic stroke: a systematic review and meta-analysis

Wii Fit-Based Biofeedback Rehabilitation Among Post-Stroke Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

BACKGROUND

Stroke is one of the most widespread reasons for acquired adult disability. Recent experimental studies have reported the beneficial influence of Wii Fit-based feedback on improving overall balance and gait for stroke survivors.

METHODS

We conducted a systematic review of the literature using the following keywords to retrieve the data: feedback, biofeedback, stroke, visual, auditory, tactile, virtual reality, videogame rehabilitation, Nintendo Wii stroke, videogame stroke, exergame stroke, Nintendo Wii rehabilitation, balance, and gait. A review and meta-analysis of RCTs regarding Wii Fit-based rehabilitation accompanied by conventional therapy effects on Berg Balance Scale (BBS), Timed Up and Go (TUG), functional reach test, and gait (speed) in stroke survivors was conducted.

OBJECTIVE

To determine the impacts of Wii Fit-based feedback combined with traditional therapy on balance and gait in stroke survivors.

RESULTS

22 studies were included. The meta-analysis results revealed statistically significant improvements in functional ambulation measured using TUG (p < 0.0001), balance measured using BBS (p = 0.0001), and functional reach test (p = 0.01), but not in gait speed (p = 0.32) following Wii Fit-based feedback. Regarding the types of feedback, significant differences were found in BBS scores when mixed visual and auditory feedback was used.

CONCLUSION

Wii Fit-based feedback has desired effects on improving balance in stroke patients, making it a suitable adjunct to physical therapy.

New approaches to recovery after stroke

After a stroke, several mechanisms of neural plasticity can be activated, which may lead to significant recovery. Rehabilitation therapies aim to restore surviving tissue over time and reorganize neural connections. With more patients surviving stroke with varying degrees of neurological impairment, new technologies have emerged as a promising option for better functional outcomes. This review explores restorative therapies based on brain-computer interfaces, robot-assisted and virtual reality, brain stimulation, and cell therapies. Brain-computer interfaces allow for the translation of brain signals into motor patterns. Robot-assisted and virtual reality therapies provide interactive interfaces that simulate real-life situations and physical support to compensate for lost motor function. Brain stimulation can modify the electrical activity of neurons in the affected cortex. Cell therapy may promote regeneration in damaged brain tissue. Taken together, these new approaches could substantially benefit specific deficits such as arm-motor control and cognitive impairment after stroke, and even the chronic phase of recovery, where traditional rehabilitation methods may be limited, and the window for repair is narrow.

Effects of virtual reality in the early-stage stroke rehabilitation: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Virtual reality (VR) is an emerging technology and has shown promising outcomes in stroke rehabilitation. VR can create an enriched environment, facilitate task-specific training, and provide multimodal sensorimotor feedback to augment functional recovery by driving the experience-dependent plasticity, which is prominent in the early-stage after stroke.

PURPOSE

This review aimed to systematically identify and examine the feasibility and effectiveness of VR intervention applied within one-month after stroke on functional outcomes of patients.

METHODS

Randomized controlled trials were searched across six databases published between 2000 and 2021. Two independent reviewers conducted study selection, data extraction, and quality assessment. Physiotherapy Evidence Database (PEDro) scale was used to evaluate the quality of included studies. Qualitative synthesis and meta-analysis were conducted to compare VR-based rehabilitation and conventional rehabilitation.

RESULTS

Seventeen randomized controlled trials were included in this review, and all of them meet the criteria for good quality. The results confirmed the feasibility of applying VR in early stroke rehabilitation. In the meta-analyses, there were no significant differences between VR and control on upper extremity function (SMD = 0.22, P = .10), Activities of Daily Living outcomes (SMD = 0.15, P = .11), balance (SMD = 0.18, P = .86), and cognition (SMD = 0.34, P = .06).

CONCLUSION

VR is a feasible approach and demonstrates comparable effectiveness in functional outcomes with conventional rehabilitation in patients with stroke at the early-stage. Further research focusing on the application of VR in acute stroke survivors with adequate sample size, additional follow-up evaluation and valid outcome measures are warranted.

Efficacy of Robot-Assisted and Virtual Reality Interventions on Balance, Gait, and Daily Function in Patients With Stroke: A Systematic Review and Network Meta-analysis

OBJECTIVE

This study aimed to evaluate the comparative effectiveness and ranking of robot-assisted training, virtual reality, and robot-assisted rehabilitation combined with virtual reality in improving balance, gait, and daily function in patients with stroke.

DATA SOURCES

PubMed, EMBASE, the Cochrane Library, Physiotherapy Evidence Database, CINAHL, Web of Science, and ProQuest Dissertations and Theses abstracting and indexing databases were comprehensively searched to include randomized controlled trials published through August 31, 2022.

STUDY SELECTION

Randomized controlled trials comparing robot-assisted training, virtual reality, robot-assisted rehabilitation combined with virtual reality, and conventional therapy to assess the effects on balance, gait, and daily function of patients with stroke.

DATA EXTRACTION

The risk of bias was assessed using the Cochrane Risk of Bias tool and the methodological quality of the studies was assessed using the Physiotherapy Evidence Database scale. A network meta-analysis of random effects models was performed for direct and indirect effects. Data were analyzed using Stata SE 17.0 and R 4.2.1.

DATA SYNTHESIS

A total of 52 randomized controlled trials involving 1,559 participants were included in this study. Based on the ranking probabilities, robot-assisted rehabilitation combined with virtual reality was most effective in improving balance (surface under the cumulative ranking curve [SUCRA]=82.0%; mean difference [MD]=4.10; 95% confidence interval [CI], 0.43 to 7.67). Virtual reality was most effective in improving velocity (SUCRA=97.8%; MD=-0.15; 95% CI, -0.24 to -0.06) and daily function (SUCRA=92.1%; MD=-7.85; 95% CI, -15.18 to -1.07).

CONCLUSIONS

Compared to robot-assisted training and conventional therapy, robot-assisted training combined virtual reality was most likely the best intervention for balance, and virtual reality might be the most helpful in improving daily function for patients after stroke. Further studies are needed to clarify the specific efficacy of robot-assisted training combined with virtual reality and virtual reality on gait.

Analysis of Physical-Cognitive Tasks Including Feedback-Based Technology for Alzheimer's Disorder in a Randomized Experimental Pilot Study

INTRODUCTION

Alzheimer's disease causes great changes, with the prefrontal cortex being the most frequently damaged zone; these changes affect physical and cognitive behavior and compromise autonomy.

OBJECTIVE

The objective of this study was to evaluate the effects of physical-cognitive tasks on memory, attention, balance, gait, and risk of falling in Alzheimer's by using feedback-based technology.

METHODS

Forty patients with Alzheimer's were recruited from an Alzheimer's Association; of these, 15 met the inclusion criteria and were included in the pilot RCT (eight in the control group; seven in the experimental group).

ASSESSMENT TOOLS

The Cognitive Mini-Examination Scale, Oddball Test and Attention Network, Berg Scale, Tinetti, Timed Up and Go, and Geriatric Deterioration Scale. The experimental group was treated with physical-cognitive tasks by using combined feedback-based technology (visual, acoustic, simultaneous, immediate, and terminal feedback, as well as knowledge of the results and performance) under the supervision of physiotherapists twice per week for 16 thirty-minute sessions. The control group underwent their usual care (pharmacological treatment, mobility exercises, and cognitive stimulation sessions).

RESULT

In the experimental group, the contrast tests showed differences for the re-test (except in attention), with the significative Timed Up and Go test being significant (p = 0.020). The interaction between groups showed significant differences for the experimental group according to the MEC (p = 0.029; d = 0.14) and Tinetti (p = 0.029; d = 0.68).

DISCUSSION/CONCLUSION

Memory, balance, gait, and risk of falling improved in the Alzheimer's patients through the use of physical-cognitive tasks involving combined feedback-based technology. The effects on attention were inconclusive. The outcomes should be treated with caution due to the sample. This can promote intergenerational bonds, use at home, and adherence to treatment.

The effects of virtual reality-based exercise in adults receiving haemodialysis treatment: A systematic review and meta-analysis of randomized controlled studies

This meta-analysis aimed to synthesize the effects of virtual reality-based exercise on physical function, depression symptoms and quality of life in adults receiving haemodialysis. Data were analysed using Comprehensive Meta-Analysis Version 3. The random-effects meta-analysis was performed to pool intervention effects. A total of five studies were included. The majority of included studies compared intervention with passive control group. This meta-analysis showed with a moderate to high quality of evidence that virtual reality-based exercise has positive medium effect on improving physical function such as gait speed (g = .40, 95% CI 0.00 to 0.81), sit to stand 10 times (g = -.41, 95% CI -0.825 to -0.009), sit to stand in 60 s (g = .56, 95% CI 0.151 to 0.974), 6-min walk test (g = .66, 95% CI 0.247 to 1.079), not affect time up and go and sit to stand five times. The study indicated with moderate quality of evidence that virtual reality-based exercise had no effect on depression symptoms. The study also showed with a moderate quality of evidence that the intervention had a positive medium effect on improving physical function (g = .64, 95% CI 0.20 to 1.09). In conclusion, virtual reality-based exercise can be performed to improve physical function and quality of life of adults receiving haemodialysis for health professionals.

The effectiveness of virtual reality games in improving cognition, mobility, and emotion in elderly post-stroke patients: a systematic review and meta-analysis

This review is aimed to assess the effectiveness of virtual reality (VR) games on cognition, mobility, and emotion in elderly stroke patients. We selected relevant articles from eight databases from 2011 to 2022 and extracted articles on cognitive ability (general cognition, mini-mental state examination (MMSE), Montreal cognitive assessment (MoCA) et al.), mobility (modified Barthel index (MBI), Fugl-Meyer assessment (FMA), Berg balance scale (BBS), functional independence measure motor (FIM MOT)), and emotion (depression/anxiety). Twenty-nine studies including 1311 participants were included in the analysis. In the results, virtual reality games were more effective in improving overall cognitive function in stroke patients compared to conventional therapies. In addition, the intervention group in the MMSE (SMD = 0.6, 95%CI = 0.26-0.95, P = 0.0007), MoCA (MD = 1.97, 95%CI = 1.3-2.64, P < 0.00001), and attention test (MD = 0.25, 95% CI = 0.01-0.49, P < 0.00001) scores were also higher. In terms of physical function, MBI (SMD = 0.61, 95%CI = 0.14-1.08, P = 0.01), FMA (SMD = 0.47, 95%CI = 0.02-0.93, P = 0.04), BBS (SMD = 0.78, 95%CI = 0.42-1.15, P < 0.0001), and FIM MOT (MD = 5.87, 95%CI = 2.57-9.17, P = 0.0005) indicators showed better results. It is also observed that virtual reality games can effectively relieve depression and improve mental health in stroke patients. Sports game training, especially with VR equipment, had a positive impact on improving the cognitive performance, mobility, and emotional state of stroke patients compared to a control group. Although the improvement in cognitive ability is relatively low, the effect of improving physical activity and depression is obvious.

Comparison of in-person and synchronous remote musculoskeletal exam using augmented reality and haptics: A pilot study

INTRODUCTION

Utilization of telemedicine for health care delivery increased rapidly during the coronavirus disease 2019 (COVID-19) pandemic. However, physical examination during telehealth visits remains limited. A novel telerehabilitation system-The Augmented Reality-based Telerehabilitation System with Haptics (ARTESH)-shows promise for performing synchronous, remote musculoskeletal examination.

OBJECTIVE

To assess the potential of ARTESH in remotely examining upper extremity passive range of motion (PROM) and maximum isometric strength (MIS).

DESIGN

In this cross-sectional pilot study, we compared the in-person (reference standard) and remote evaluations (ARTESH) of participants' upper extremity PROM and MIS in 10 shoulder and arm movements. The evaluators were blinded to each other's results.

SETTING

Participants underwent in-person evaluations at a Veterans Affairs hospital's outpatient Physical Medicine and Rehabilitation (PM&R) clinic, and underwent remote examination using ARTESH with the evaluator located at a research lab 30 miles away, connected via a high-speed network.

PATIENTS

Fifteen participants with upper extremity pain and/or weakness.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Inter-rater agreement between in-person and remote evaluations on 10 PROM and MIS movements and presence/absence of pain with movement was calculated.

RESULTS

The highest inter-rater agreements were noted in shoulder abduction and protraction PROM (kappa (κ) = 0.44, confidence interval (CI): -0.1 to 1.0), and in elbow flexion, shoulder abduction, and shoulder protraction MIS (κ = 0.63, CI: 0 to 1.0).

CONCLUSIONS

This pilot study suggests that synchronous tele-physical examination using the ARTESH system with augmented reality and haptics has the potential to provide enhanced value to existing telemedicine platforms. With the additional technological and procedural improvements and with an adequately powered study, the accuracy of ARTESH-enabled remote tele-physical examinations can be better evaluated.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

The effects of Robot-assisted gait training and virtual reality on balance and gait in stroke survivors: A randomized controlled trial

BACKGROUND

Stroke survivors often experience balance and gait problems, which can affect their quality of life and independence in daily living activities. Robot-assisted gait training, such as Lokomat with virtual reality, has been found to be effective in improving gait and balance. However, the specific effects of each virtual reality application on balance and spatiotemporal parameters of gait are not yet established. This study aims to investigate the effects of different virtual reality applications on these parameters.

RESEARCH QUESTION

What are the specific effects of each Lokomat augmented performance feedback application on balance and spatiotemporal parameters of gait in stroke survivors?

METHODS

The study is a randomized controlled trial conducted with four groups: Control Group, Endurance Group, Attention and Motivation Group, and Activity Timing Group. All participants received six weeks of physiotherapy, and Lokomat groups had additional robot-assisted gait training with Lokomat for three days a week. The Endurance group used Lokomat with Faster, Attention and Motivation Group with Gabarello and Smile, and Activity Timing Group with Curve Pursuit, Treasures, and High Flyer applications. Various tests were used to assess walking and balance in the study (gait analysis, 6-minute walk test, 10-meter walk test, Berg Balance Scale, postural stability, and limits of stability).

RESULTS AND SIGNIFICANCE

The study involved 56 male stroke survivors (mean age: 60.02 ± 6.83 years, post-stroke time: 238.88 ± 40.88 days). All groups improved walking speed and distance significantly, but Endurance was better (p < 0.001). Balance improved significantly in all groups, but Attention and Motivation was superior in Berg Balance Scale, postural stability, and limits of stability (p < 0.001). The selection of virtual reality applications during robot-assisted gait training according to rehabilitation goals is important for successful rehabilitation, as these applications may have varying effects on balance and walking.

Effects of Virtual Reality on the Limb Motor Function, Balance, Gait, and Daily Function of Patients with Stroke: Systematic Review

Background and Objectives: This systematic review aimed to clarify the effectiveness of virtual reality rehabilitation on physical outcomes for people with stroke. Materials and Methods: Articles were searched through PubMed, EMBASE, the Cochrane Library, the Physiotherapy Evidence Database, CINAHL, Web of Science, and ProQuest Dissertations and Theses, from inception to 30 April 2022. Methodological quality was scored using the Assessing the Methodological Quality of Systematic Reviews 2 tool. Each systematic review for the outcome of interest was assessed by two independent reviewers using the Grading of Recommendations Assessment, Development, and Evaluation system. Results: Twenty-six articles were selected. These studies evaluated the effectiveness of virtual reality on limb motor function, balance, gait, and daily function in patients with stroke. The findings suggested a beneficial effect of virtual reality; there was a "very low" to "moderate" quality of evidence for improved limb extremity function, balance, and daily function, and a "very low" to "moderate" quality of evidence for improved gait. Conclusions: Despite widespread interest in the use of virtual reality rehabilitation, high-quality evidence for its routine use in stroke treatment is lacking. Further research is needed to determine the treatment modality, duration, and long-term effects of virtual reality on stroke populations.

Immersive Virtual Reality in Post-Stroke Rehabilitation: A Systematic Review

In recent years, next to conventional rehabilitation's techniques, new technologies have been applied in stroke rehabilitation. In this context, fully immersive virtual reality (FIVR) has showed interesting results thanks to the level of immersion of the subject in the illusional world, with the feeling of being a real part of the virtual environment. This study aims to investigate the efficacy of FIVR in stroke rehabilitation. PubMed, Web of Science and Scopus were screened up to November 2022 to identify eligible randomized controlled trials (RCTs). Out of 4623, we included 12 RCTs involving post-acute and chronic stroke survivors, with a total of 350 patients (234 men and 115 women; mean age 58.36 years). High heterogeneity of the outcomes considered, the results showed that FIVR provides additional benefits, in comparison with standard rehabilitation. In particular, results showed an improvement in upper limb dexterity, gait performance and dynamic balance, influencing patient independence. Therefore, FIVR represents an adaptable, multi-faceted rehabilitation tool that can be considered in post-stroke rehabilitation, improving the compliance of the patients to the treatment and increasing the level of functioning and quality of life of stroke survivors.

Virtual Reality for Motor and Cognitive Rehabilitation

Virtual Reality (VR) affords clinicians the ability to deliver safe, controlled, task-specific customised interventions that are enjoyable, motivating and engaging. Elements of training in VR comply with principles of learning implicated in new skill acquisition and re-learning skills post-neurological disorders. However, heterogeneity in the description of VR systems and the description and control of 'active' ingredients of interventions (like dosage, type of feedback, task specificity, etc.) have led to inconsistency in the synthesis and interpretation of evidence related to the effectiveness of VR-based interventions, particularly in post-stroke and Parkinson's Disease (PD) rehabilitation. This chapter attempts to describe VR interventions with respect to their compliance with principles of neurorehabilitation, with the goal of optimising interventions for effective training and facilitation of maximum functional recovery. This chapter also advocates using a uniform framework to describe VR systems to promote homogeneity in literature in order to help in the synthesis of evidence. An overview of the evidence revealed that VR systems are effective in mediating deficits in upper extremity, posture and gait function seen in people post-stroke and PD. Generally, interventions were more effective when they were delivered as an adjunct to conventional therapy and were customised for rehabilitation purposes, in addition to complying with principles of learning and neurorehabilitation. Although recent studies imply that their VR intervention is compliant with principles of learning, only a few explicitly describe how these principles are incorporated as 'active ingredients' of the intervention. Finally, VR interventions targeting community ambulation and cognitive rehabilitation are yet limited and therefore warrant attention.

The effects of dynamic motion instability system training on motor function and balance after stroke: A randomized trial

BACKGROUND

The balance and postural control of humans is related to the coordination of dynamic perception and movement. Multiple senses, such as vision, vestibular sense, proprioception, and/or a single sensory disorder, would lead to its integration disorder and induce imbalance and abnormal gait.

OBJECTIVE

The present study aimed to determine the effects of dynamic motion instability system training (DMIST) on the balance and motor function of hemiplegic patients after stroke.

METHODS

In this assessor-blinded, randomized controlled trial, the participants allocated to the intervention group (n = 20) received 30 minutes of conventional treatment and 20 minutes of DMIST training. Participants randomized to the control group (n = 20) received the same dose of conventional therapy and 20 minutes of general balance training. Rehabilitation was performed 5 times per week for 8 weeks. The primary outcome was the Fugl-Meyer assessment for the lower extremity (FMA-LE), and the secondary outcomes were the Berg balance scale (BBS) and gait function. Data were collected at baseline and immediately after the intervention.

RESULTS

After 8 weeks (t1), both groups showed significant post-intervention improvements in BBS, FMA-LE, gait speed and stride length (P < 0.05); there were significant positive correlations between the increase in FMA-LE and gait speed and stride length. Compared with the control group, the DMIST group showed significant post-intervention improvements in FMA-LE, gait speed and stride length (P < 0.05). However, no significant differences between the groups were found over time with respect to BBS (P > 0.05). The experiences of patients with DMIST were positive, and no serious adverse events were related to the interventions.

CONCLUSION

Supervised DMIST could be highly effective in treating lower-limb motor function in patients with stroke. Frequent (weekly) and medium-term (8 weeks) dynamic motion instability-guided interventions might be highly effective in enhancing motor function, and subsequently improving gait in stroke patients.

Effectiveness of feedback-based technology on physical and cognitive abilities in the elderly

Aging raises a social and health challenge because the passing of time causes changes in cognitive and physical functions that impair functionality and quality of life. In addition, advancements in technology and information technology have led to the development of new techniques for retraining based on the feedback technology provides. To solve the negative consequences of aging, a randomized clinical trial was carried out to assess the effectiveness of a protocol using feedback-based technology to improve physical and cognitive functions in older adults. For the purpose of this study, 200 patients were selected from a Social and Community Services Center in the province of Seville and only 46 of them became participants of the study (after applying the inclusion criteria). These patients were divided into two groups: control and experimental. Physical and cognitive abilities were assessed using the Miniexamen cognoscitivo Test (an adaptation of the MiniMental examination test), Yesevage's Depression Scale, Oddball Test, Attention Network Test, Berg Scale, Tinetti Scale, and Timed Up and Go Test. The intervention applied to the experimental group consisted of a supervised protocol using the Nintendo® Wii video game console and the Wii-Fit© video game during 16 sessions, 2 times a week with a duration of 30 min per session. The control group did not receive any treatment. The experimental group showed statistically significant improvements in all the physical variables (balance, gait, autonomy, and fall risk), as other authors had proven, and in memory and reaction times; there were no improvements in attention networks. The control group (placebo) even showed a decrease in their functions, with worse results on the Timed up and Go test Scale. The intervention using feedback-based technology has been proven effective in improving physical and cognitive abilities and in preventing and promoting healthy aging.

Virtual reality gaming in rehabilitation after stroke - user experiences and perceptions

PURPOSE

The present study explored participants' experiences with and perceptions of using fully immersive head-mounted virtual reality (VR) gaming as rehabilitation after stroke.

METHODS

Four men and three women (median age 64 years) with chronic stroke and varying motor impairment (mild to severe) were interviewed after 10 weeks of VR training on the commercial HTC Vive system, focusing on the upper extremities. Inductive qualitative thematic analysis was performed.

RESULTS

The analysis revealed three main themes: playing the game, benefits and effects, and personalizing the game. Playing the game encompasses both the feeling of being immersed in the game and descriptions of the gaming being motivating and fun. Benefits and effects describe the participants' expectations of potential benefits, the importance of getting feed-back, and the impact in daily life. Personalizing the game includes finding the right game and level, and the participants' need for support to achieve full use of the training.

CONCLUSIONS

Participants with chronic stroke described the fully immersive VR gaming intervention as a fun and motivating way to improve their functioning in everyday life. Qualitative studies are needed to explore how people with stroke perceive VR gaming when it is implemented in real clinical environments.Clinical implicationsVR gaming was perceived as a positive and motivating rehabilitation after stroke.Getting feedback and perceiving benefits are essential parts of VR rehabilitation.Commercial fully immersive VR-games might be an option for stroke rehabilitation when the game can be personalized and support is available.

Effectiveness of Virtual Reality on Balance and Risk of Falls in People with Multiple Sclerosis: A Systematic Review and Meta-Analysis

The aim of this study was to systematically review the scientific evidence related to the physiotherapy interventions in neurorehabilitation that utilize virtual reality (VR) for balance training and risk of falls in people with multiple sclerosis (MS). A search was conducted in Medline (PubMed), PEDro, and Google Scholar to identify all the relevant studies. Clinical trials assessing the effects of VR in people with MS were included. Risk of bias was evaluated using the Cochrane Risk of Bias Tool and PEDro scale. Qualitative analysis was performed according to the GRADE. In total, 16 studies (n = 663) were included. The meta-analysis showed statistically significant differences for the VR intervention in comparison with conventional treatment for balance, with a moderate clinical effect in eight studies (SMD: 0.63; 95% CI 0.34-0.92; p < 0.05). In addition, the meta-analysis showed statistically significant differences for the VR intervention in comparison with conventional treatment for risk of falls, with a small clinical effect in six studies (SMD: -0.55; 95% CI -1.07-0.04; p < 0.05). VR-based treatments are more effective than non-intervention in improving balance and fall risk in people with MS, with a very low certainty of evidence. In addition, they also show to be more effective than conventional rehabilitation, with a very low certainty of evidence.

Effects of a social participation-focused virtual reality intervention for community-dwelling stroke survivors with physical disabilities: a randomised controlled trial protocol

INTRODUCTION

Studies show that stroke survivors encounter physical and psychological limitations that restrict their participation in social and community activities. Systematic reviews have yielded inconclusive evidence regarding the effectiveness of different interventions intended to support stroke survivors' social participation. Recent advances in virtual reality technology may offer promising solutions, although the optimal approach to enhance social participation among stroke survivors is yet to be determined. This trial aims to develop and evaluate the effectiveness of a social participation-focused virtual reality (SP-VR) intervention on the physical, psychological and social outcomes of community-dwelling stroke survivors with physical disabilities.

METHODS AND ANALYSIS

A two-arm randomised, controlled, assessor-blind clinical trial will be conducted with 250 stroke survivor-caregiver dyads recruited from three acute and one rehabilitation hospitals, and three stroke nurse-led clinics. Participants will be survivors of a first or recurrent stroke within 6 months of stroke onset and able to remain in a sitting position without support, and their primary caregivers. Eligible participants will be randomly allocated to receive the SP-VR intervention or usual care which includes conventional physical therapy services. The intervention group will receive a newly developed 6-week novel custom-made SP-VR application comprising two sessions weekly. Three SP-VR modules will cover key aspects of survivors' social health needs, namely functional rehabilitation, social participation, and social interaction and recreation. The primary outcome for stroke survivors is social participation, and secondary outcomes include depressive symptoms, participation self-efficacy, physical function, functional mobility and social support. User satisfaction will be evaluated among both survivors and caregivers. Data will be collected in person at baseline, immediately after, and 3 months postintervention.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Research Ethics Committee (Ref. No.: 2019.676). Study results will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2100050850.

Virtual Reality Rehabilitation Systems for Cancer Survivors: A Narrative Review of the Literature

Rehabilitation plays a crucial role in cancer care, as the functioning of cancer survivors is frequently compromised by impairments that can result from the disease itself but also from the long-term sequelae of the treatment. Nevertheless, the current literature shows that only a minority of patients receive physical and/or cognitive rehabilitation. This lack of rehabilitative care is a consequence of many factors, one of which includes the transportation issues linked to disability that limit the patient’s access to rehabilitation facilities. The recent COVID-19 pandemic has further shown the benefits of improving telemedicine and home-based rehabilitative interventions to facilitate the delivery of rehabilitation programs when attendance at healthcare facilities is an obstacle. In recent years, researchers have been investigating the benefits of the application of virtual reality to rehabilitation. Virtual reality is shown to improve adherence and training intensity through gamification, allow the replication of real-life scenarios, and stimulate patients in a multimodal manner. In our present work, we offer an overview of the present literature on virtual reality-implemented cancer rehabilitation. The existence of wide margins for technological development allows us to expect further improvements, but more randomized controlled trials are needed to confirm the hypothesis that VRR may improve adherence rates and facilitate telerehabilitation.

VR in Nursing Facilities - A randomized controlled multicenter pilot study analyzing the changes in the state of mind of seniors in nursing facilities through the viewing of 360° videos

Context

VR as an application to enhance well-being is sparsely researched in the elderly population. The aim of the pilot study was to analyze the effect of 360° videos of different categories on the state of mind of seniors in nursing facilities. Furthermore, for the implementation in everyday life, the usability of the system and the experience for seniors should be evaluated.

Methods

The VR experience was used as a supplement to existing care services in three facilities on eight subjects. Mood state was assessed using the Questionnaire for the Assessment of Happiness before and after the intervention. Demographic data and technology acceptance were collected beforehand. After the intervention, subjects were interviewed about confounding factors and side effects, and nursing home staff were interviewed about the usability of the system and the organizational concept of implementation.

Results

There was a positive effect on state of mind. Gender and spatial mobility turned out to be influencing factors. Categories containing people, animals and action achieved the highest increases in the state of mind. Interest in using technical devices correlated negatively with the change in mood state. None of the subjects found the VR goggles distracting or reported motion sickness. Very good usability was indicated by the employees.

Conclusion

A very high willingness to use this technology was found among nursing staff and residents. The tendencies of the positive effect of 360° videos on the state of mind, as well as differentiation based on the mentioned characteristics gender and spatial mobility, should be verified by a larger sample to empirically validate the use of this technology to increase the quality of life.

Effect of Wii Fit Exercise With Balance and Lower Limb Muscle Strength in Older Adults: A Meta-Analysis

Background

Falls and fall-related injuries are not uncommon among older adults and may lead to serious health deterioration and decreased quality of life. Numerous types of physical activity have been proposed to improve balance and strength in older adults with varying degrees of success. Nintendo's Wii Fit video exergame uses body movement as a game controller and provides real-time feedback for games designed to enhance balance and muscle strength. However, whether Wii Fit exercise improves the balance and lower limb muscle strength of older adults remains uncertain.

Objective

To evaluate the current literature by using meta-analyses to assess whether Wii Fit exercise is associated with improved balance and lower limb muscle strength in older adults.

Methods

We searched PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure, and Wanfang Data from inception to February 16, 2022, for relevant studies and conducted a manual search of the literature. Data extraction of the included studies were independently performed by two authors. The methodologic quality of each included study was assessed using the Physical Therapy Evidence Database (PEDro) scale. Meta-analyses were conducted using Review Manager 5.3.

Results

Of 991 articles initially identified, 10 articles (379 participants; aged ≥65 years, range 65–92 years; 188 participants in Wii Fit exercise groups, and 191 participants in control groups), including 8 randomized controlled trials, were assessed in this meta-analysis. The methodologic quality of the included studies evaluated with the PEDro average score was 6.4 and ranged from 5 to 8 points, indicating moderate quality. Compared with no exercise, Wii Fit exercise was associated with significant improved scores on the Berg Balance Scale, which evaluates functional balance (mean difference, 1.38; 95% CI, 0.61–2.16; I² = 31%; P = 0.0005) and on the Timed Up and Go test, which evaluates static and dynamic balance (standardized mean difference, −0.51; 95% CI,−0.88 to −0.14; I² = 52%; P = 0.007). However, for the three studies assessed, Wii Fit exercise did not significantly improve scores on the 30-s chair stand test, which evaluates the functional strength and endurance of the lower limb muscles (mean difference, 0.82; 95% CI, −0.14 to 1.77; z = 1.68; P = 0.09).

Conclusions

Our findings indicated that Wii Fit exercise is an effective approach to improve functional, static, and dynamic balance among older adults. Additional meta-analyzes with higher numbers of randomized controlled trials are suggested to confirm the benefits of Wii Fit exercise on balance in older adults, to establish whether functional strength and endurance of lower limb muscles are improved, and to explore the relationship between improved balance and fall prevention in this population.

Designing Spellcasters from Clinician Perspectives

Developing games is time-consuming and costly. Overly clinical therapy games run the risk of being boring, which defeats the purpose of using games to motivate healing in the first place [10, 23]. In this work, we adapt and repurpose an existing immersive virtual reality (iVR) game, Spellcasters, originally designed purely for entertainment for use as a stroke rehabilitation game—which is particularly relevant in the wake of COVID-19, where telehealth solutions are increasingly needed [4]. In preparation for participatory design sessions with stroke survivors, we collaborate with 14 medical professionals to ensure Spellcasters is safe and therapeutically valid for clinical adoption. We present our novel VR sandbox implementation that allows medical professionals to customize appropriate gestures and interactions for each patient's unique needs. Additionally, we share a co-designed companion app prototype based on clinicians' preferred data reporting mechanisms for telehealth. We discuss insights about adapting and repurposing entertainment games as serious games for health, features that clinicians value, and the potential broader impacts of applications like Spellcasters for stroke management.

Maze Control Training on Kinesthetic Awareness in Patients with Stroke: A Randomized Controlled Trial

Objective

To determine the influence of adding maze control training to the selected conventional physical therapy on kinesthetic awareness in patients with chronic stroke.

Methods

Thirty adult patients of both genders with chronic cerebral stroke were assigned to control and experimental groups randomly: the control group (A) received the selected conventional physical therapy rehabilitation program, while the experimental group (B) received the same program as group A in addition to the maze control training. Measurements for sway index, risk of fall, and knee proprioception before and after 8 weeks of treatment (24 sessions; three times per week).

Results

There were significant decreases of both sway index and risk of fall in both groups (p ≤ 0.001 in all measures), significant improvements of the knee proprioception in 30° and 75° in the experimental group (p value = 0.016 and ≤0.001, respectively). The in-between groups' comparison showed significant differences corresponding to both the sway index and risk of fall (p ≤ 0.001), and a significant difference in 75° (p ≤ 0.001).

Conclusion

Adding maze control training to the selected conventional physical therapy improved the kinesthetic awareness in patients with chronic stroke.

Design, development, and testing of a virtual reality device for upper limb training in people with multiple sclerosis: a feasibility study (Preprint)

Background

Multiple sclerosis (MS) is a common nontraumatic, neurological, disabling disease that often presents with upper limb dysfunction. Exercise training has resulted in improvement for patients; however, there can be a lack of compliance due to access because of location and lack of MS experts. Virtual reality (VR) is a promising technology that can offer exercise therapy/rehabilitation at a distance. This type of remote training can be motivational and effective for patients with MS and can improve range of motion and muscle strength for those with upper limb dysfunction.

Objective

The aim of this study is to evaluate the safety and feasibility of the XRHealth software and the Oculus Rift Station for patients with MS with upper limb motor dysfunction.

Methods

A single-center, prospective, feasibility study was conducted with patients with MS who had upper limb motor dysfunction. Patients participated in a single 45-minute digital environment session with VR and completed a questionnaire about the quality of the training and fatigability. The clinician also completed a questionnaire to evaluate the suitability and safety of the training.

Results

Overall, 30 patients were enrolled between the ages of 20 and 81 years. Patients reported that the training sessions within the digital environment were helpful, challenging, fun, and simple to understand, and that they would be willing to repeat the sessions again. The physical therapist that oversaw the patients reported that the training was suitable for 87% (n=26) of the patients. Anticipated adverse events were fatigue, temporary dizziness, and temporary nausea. The operator complications included that the cable of the head-mounted display interrupted the training (n=2, 7%) and fatigue that caused cessation of the VR training session (n=2, 7%). No serious adverse events were reported.

Conclusions

These preliminary results demonstrated that the use of the XRHealth software and Oculus Rift Station platform is feasible, safe, and engaging for patients, and has the potential to improve the functionality of the upper limbs in patients with MS. This study provides support for future studies of implementing a series of training sessions with virtual reality in a home-based environment.

Effects of exergaming on functional outcomes in people with chronic stroke: A systematic review and meta-analysis

AIMS

The aim of this review is to synthesize and evaluate effectiveness of exergaming on balance, lower limb functional mobility and functional independence in individuals with chronic stroke.

DESIGN

The present review is a systematic review and meta-analysis. The review is written in accordance with the guidelines from the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) DATA SOURCE: Searches were conducted across seven databases (PubMed, EMBASE, Web of Science, CINAHL, CENTRAL, Scopus and PEDro) and in grey literature from inception until January 2021.

REVIEW METHODS

Only randomized controlled trials (RCTs) written in English were included. All eligible studies were assessed for risk of bias by two reviewers independently. Meta-analyses were performed using RevMan 5.4.1 software. Narrative syntheses were adopted whenever meta-analysis was inappropriate. The overall quality of evidence from included studies was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework.

RESULTS

4511 records were retrieved, with 32 RCTs eligible for inclusion and 27 RCTs included in meta-analysis. Meta-analyses reported statistically significant small effect sizes favouring exergaming on balance (pooled standardized mean difference [SMD] = 0.25, 95% confidence interval [CI, 0.08-0.41], p = .004), lower limb functional mobility (pooled SMD = 0.29, 95% CI [0.08-0.50], p = .007) and functional independence (pooled SMD = 0.41, 95% CI [0.09-0.73], p = .01). Most of the included studies failed to provide adequate description of the measures taken to prevent bias.

CONCLUSION

Exergaming has favourable effects on improving balance, lower limb functional mobility and functional independence among individuals with chronic stroke, making it a suitable adjunct to conventional physiotherapy.

IMPACT

People with chronic stroke have difficulty achieving the required rehab intensity. Exergaming can help individuals with chronic stroke to undertake further rehabilitation exercises at home. It can be a suitable adjunct to conventional physiotherapy.

Virtual Reality and Physiotherapy in Post-Stroke Functional Re-Education of the Lower Extremity: A Controlled Clinical Trial on a New Approach

Numerous Virtual Reality (VR) systems address post-stroke functional recovery of the lower extremity (LE), most of them with low early applicability due to the gait autonomy they require. The aim of the present study was to evaluate the feasibility of a specific VR treatment and its clinical effect on LE functionality, gait, balance, and trunk control post-stroke. A controlled, prospective, clinical trial was carried out with 20 stroke patients, who were divided into two groups: the first group (VR + CP; n = 10) received combined therapy of 1 h VR and 1 h of conventional physiotherapy (CP) and the second group (CP; n = 10) received 2 h of CP (5 days/week, for 3 weeks). The following pre-post-intervention measuring scales were used: Functional Ambulatory Scale (FAC), Functional Independence Measure (FIM), Fugl-Meyer Assessment (FM), Berg Balance Scale (BBS), and Trunk Control Test (TCT). Only VR + CP showed a significant improvement in FAC. In FIM, CP presented a tendency to significance, whereas VR + CP showed significance. Both groups improved significantly in FM (especially in amplitude/pain in VR + CP and in sensitivity in CP) and in BBS. In TCT, there was a non-significant improvement in both groups. The results indicate that the intervention with VR is a feasible treatment in the post-stroke functional re-education of the LE, with the potential to be an optimal complement of CP.

Personalized Motor-Cognitive Exergame Training in Chronic Stroke Patients-A Feasibility Study

Purpose: Exergame training may be beneficial for improving long-term outcome in stroke patients. Personalized training prescription applying progression rules, is missing. We adapted a theory-based taxonomy for a rehabilitation approach using user-centered exergames. The aims were primarily to investigate the feasibility of this rehabilitation approach, and secondarily to evaluate its performance of personalizing training progression, as well as explore the effects on secondary outcomes.

Methods: Chronic stroke patients (≥ 18 years) were included, who were able to walk 10 meters and stand for 3 min. The rehabilitation approach was administered twice per week for 8 weeks. As primary outcome, feasibility was evaluated by comparing achieved rates of inclusion, adherence, compliance, attrition, motivation, and satisfaction to pre-defined thresholds for acceptance. Secondary outcomes were (1) perceived motor and cognitive task difficulty throughout the intervention; (2) measures collected during baseline and post-measurements—a gait analysis, the Timed-up-and-go test (TUG), several cognitive tests assessing attentional, executive, and visuospatial functions.

Results: Thirteen patients [median: 68.0 (IQR: 49.5–73.5) years, median: 34.5 (IQR: 12.25–90.75) months post-stroke] were included, of whom ten completed the study. Rates for inclusion (57%), adherence (95%), compliance (99%), motivation (77%), and satisfaction (74%) were acceptable, however, the attrition rate was high (23%). The perceived motor and cognitive task difficulty predominantly moved below the targeted range. We found a significant change in the TUG (p = 0.05, r = 0.46) and medium-to-large effect sizes (p > 0.05) for swing time of the affected leg, the asymmetry index, time needed for the Trail-making test (TMT) A and accuracy for the TMT B and the Mental Rotation Test (MRT; 0.26 ≤ r ≤ 0.46).

Discussion: The intervention was feasible with minor modifications necessary, which warrants a larger trial investigating the effects of the rehabilitation approach following the adapted taxonomy on mobility, gait and cognitive functions. Two main limitations of the rehabilitation approach were; (1) the taxonomy decoupled motor and cognitive progression, which may be improper as motor and cognitive learning is coupled; (2) separate subjective ratings were used to guide the progression. Future studies should develop an instrument to objectively assess motor-cognitive task difficulty for monitoring the progression of an exergame-based training.

Effects of Virtual Reality Training on Upper Limb Function and Balance in Stroke Patients: Systematic Review and Meta-Meta-Analysis

Background

Virtual reality (VR) training is a promising intervention strategy that has been utilized in health care fields like stroke rehabilitation and psychotherapy. Current studies suggest that VR training is effective in improving the locomotor ability of stroke patients.

Objective

This is the first meta-meta-analysis of the effects of VR on motor function in stroke patients. This study aimed to systematically summarize and quantify the present meta-analyses results of VR training and produce high-quality meta-meta-analysis results to obtain a more accurate prediction.

Methods

We searched 4 online databases (Web of Science, Scopus, PubMed, and Chinese National Knowledge Infrastructure) for meta-analysis studies. After accounting for overlap, 10 studies (accounting for almost 550 stroke patients) were obtained. Based on the meta-meta-analysis of these patients, this study quantified the impact of VR training on stroke patients’ motor performance, mainly including upper limb function, balance, and walking ability. We combined the effects under the random effect model and pooled the estimates as standardized mean differences (SMD).

Results

The results of the meta-meta-analysis showed that VR training effectively improves upper limb function (SMD 4.606, 95% CI 2.733-6.479, P<.05) and balance (SMD 2.101, 95% CI 0.202-4.000, P<.05) of stroke patients. However, the results showed considerable heterogeneity and thus, may need to be treated with caution. Due to the limited research, a meta-meta-analysis of walking ability was not performed.

Conclusions

These findings represent a comprehensive body of high-quality evidence that VR training is more effective at improving upper limb function and balance of stroke patients.

Movement System Diagnoses for Balance Dysfunction: Recommendations From the Academy of Neurologic Physical Therapy's Movement System Task Force

The movement system was identified as the focus of our expertise as physical therapists in the revised vision statement for the profession adopted by the American Physical Therapy Association in 2013. Attaining success with the profession's vision requires the development of movement system diagnoses that will be useful in clinical practice, research, and education. To date, only a few movement system diagnoses have been identified and described, and none of these specifically address balance dysfunction. Over the past 2 years, a Balance Diagnosis Task Force, a subgroup of the Movement System Task Force of the Academy of Neurologic Physical Therapy, focused on developing diagnostic labels (or diagnoses) for individuals with balance problems. This paper presents the work of the task force that followed a systematic process to review available diagnostic frameworks related to balance, identify 10 distinct movement system diagnoses that reflect balance dysfunction, and develop complete descriptions of examination findings associated with each balance diagnosis. A standardized approach to movement analysis of core tasks, the Framework for Movement Analysis developed by the Academy of Neurologic Physical Therapy Movement Analysis Task Force, was integrated into the examination and diagnostic processes. The aims of this perspective paper are to (1) summarize the process followed by the Balance Diagnosis Task Force to develop an initial set of movement system (balance) diagnoses; (2) report the recommended diagnostic labels and associated descriptions; (3) demonstrate the clinical decision-making process used to determine a balance diagnosis and develop a plan of care; and (4) identify next steps to validate and implement the diagnoses into physical therapist practice, education, and research.

IMPACT

The development and use of diagnostic labels to classify distinct movement system problems is needed in physical therapy. The 10 balance diagnosis proposed can aid in clinical decision making regarding intervention.

The Effect of Virtual Reality Training on Anticipatory Postural Adjustments in Patients with Chronic Nonspecific Low Back Pain: A Preliminary Study

Objectives

This study is aimed at exploring the effects of virtual reality (VR) training on postural control, measured by anticipatory and compensatory postural adjustments (APAs and CPAs, respectively), in patients with chronic nonspecific low back pain (CNLBP) and the potential neuromuscular mechanism of VR training.

Methods

Thirty-four patients were recruited and randomly assigned to the VR group (n = 11), the motor control exercise group (MCE, n = 12) and the control group (CG, n = 11). The VR group received VR training using Kinect Xbox 360 systems and magnetic therapy. Besides magnetic therapy, the participants in the MCE group performed real-time ultrasound-guided abdominal drawing-in maneuver (ADIM) and four-point kneeling exercise. The CG only received magnetic therapy. Surface muscle electromyography (sEMG) was used to record the muscle activities of transverse abdominis (TrA), multifidus (MF), lateral gastrocnemius (LG), and tibialis anterior (TA) during ball-hitting tasks. The muscle activation time and integrals of the electromyography activities (IEMGs) during the APA and CPA stages were calculated and used in the data analysis. The visual analogue scale (VAS) and Oswestry dysfunction index (ODI) scores were also recorded.

Results

A significant interaction effect of time × group was observed on the activation time of TrA (p = 0.018) and MF (p = 0.037). The post-intervention activation time of the TrA was earlier in the VR group (p = 0.029). In contrast, the post-intervention activation time of the MF was significantly delayed in the VR group (p = 0.001). The IEMGs of TrA (p = 0.002) and TA (p = 0.007) during CPA1 significantly decreased only in the VR group after the intervention. The VAS scores of three group participants showed significant decreases after intervention (p < 0.001).

Conclusions

Patients with CNLBP showed reciprocal muscle activation patterns of the TrA and MF muscles after VR training. VR training may be a potential intervention for enhancing the APAs of the patients with CNLBP.

Effectiveness of virtual reality-based rehabilitation versus conventional therapy on upper limb motor function of chronic stroke patients: a systematic review and meta-analysis of randomized controlled trials

Objective: To systematically review the available randomized controlled trials in the literature concerning the application of virtual reality (VR) rehabilitation interventions compared to conventional physical therapy, in regaining the upper limb motor function among patients with chronic stroke. Methods: A systematic electronic database search was conducted for related studies published from inauguration and until June 25, 2020 in nine databases. Another new search was done on February 1, 2021 and no new studies were identified. Results: Six studies were included in the analysis. Significant improvement was seen following the VR therapy in patients with chronic stroke, compared to their scores prior to it (SMD = 0.28; 95% CI = 0.03-0.53; p = .03). There was neither heterogeneity (I² = 0% and P = .5) nor a risk of bias (P = .8) among the included studies. VR interventions produced a comparable effectiveness to that of the conventional rehabilitation, with no statistically significant difference (SMD = 0.15; 95% CI = -0.14-0.44; P = .3). There was neither heterogeneity (I² = 40% and P = .1) nor a risk of bias (P = .5) among the included studies. Conclusions: The upper limb motor function of patients with chronic stroke who underwent VR-based rehabilitative intervention showed significant improvement as compared to the pre-treatment state. Our analysis also revealed no superiority of VR interventions over conservative therapies; however, the difference observed did not accomplish statistical significance.

The Challenges and Perspectives of the Integration Between Virtual and Augmented Reality and Manual Therapies

Virtual reality (VR) and augmented reality (AR) have been combined with physical rehabilitation and psychological treatments to improve patients' emotional reactions, body image, and physical function. Nonetheless, no detailed investigation assessed the relationship between VR or AR manual therapies (MTs), which are touch-based approaches that involve the manipulation of tissues for relieving pain and improving balance, postural stability and well-being in several pathological conditions. The present review attempts to explore whether and how VR and AR might be integrated with MTs to improve patient care, with particular attention to balance and to fields like chronic pain that need an approach that engages both mind and body. MTs rely essentially on touch to induce tactile, proprioceptive, and interoceptive stimulations, whereas VR and AR rely mainly on visual, auditory, and proprioceptive stimulations. MTs might increase patients' overall immersion in the virtual experience by inducing parasympathetic tone and relaxing the mind, thus enhancing VR and AR effects. VR and AR could help manual therapists overcome patients' negative beliefs about pain, address pain-related emotional issues, and educate them about functional posture and movements. VR and AR could also engage and change the sensorimotor neural maps that the brain uses to cope with environmental stressors. Hence, combining MTs with VR and AR could define a whole mind-body intervention that uses psychological, interoceptive, and exteroceptive stimulations for rebalancing sensorimotor integration, distorted perceptions, including visual, and body images. Regarding the technology needed to integrate VR and AR with MTs, head-mounted displays could be the most suitable devices due to being low-cost, also allowing patients to follow VR therapy at home. There is enough evidence to argue that integrating MTs with VR and AR could help manual therapists offer patients better and comprehensive treatments. However, therapists need valid tools to identify which patients would benefit from VR and AR to avoid potential adverse effects, and both therapists and patients have to be involved in the development of VR and AR applications to define truly patient-centered therapies. Furthermore, future studies should assess whether the integration between MTs and VR or AR is practically feasible, safe, and clinically useful.

Effectiveness of Virtual/Augmented Reality-Based Therapeutic Interventions on Individuals With Autism Spectrum Disorder: A Comprehensive Meta-Analysis

In recent years, the application of virtual reality (VR) for therapeutic purposes has escalated dramatically. Favorable properties of VR for engaging patients with autism, in particular, have motivated an enormous body of investigations targeting autism-related disabilities with this technology. This study aims to provide a comprehensive meta-analysis for evaluating the effectiveness of VR on the rehabilitation and training of individuals diagnosed with an autism spectrum disorder. Accordingly, we conducted a systematic search of related databases and, after screening for inclusion criteria, reviewed 33 studies for more detailed analysis. Results revealed that individuals undergoing VR training have remarkable improvements with a relatively large effect size with Hedges g of 0.74. Furthermore, the results of the analysis of different skills indicated diverse effectiveness. The strongest effect was observed for daily living skills (g = 1.15). This effect was moderate for other skills: g = 0.45 for cognitive skills, g = 0.46 for emotion regulation and recognition skills, and g = 0.69 for social and communication skills. Moreover, five studies that had used augmented reality also showed promising efficacy (g = 0.92) that calls for more research on this tool. In conclusion, the application of VR-based settings in clinical practice is highly encouraged, although their standardization and customization need more research.

A Clinical Decision-Making Framework for the Use of Video Gaming as a Therapeutic Modality

Virtual reality and video gaming offer modulation of more exercise and motor learning parameters simultaneously than other modalities; however, there is a demonstrated need for resources to facilitate their effective use clinically. This article presents a conceptual framework to guide clinical-decision making for the selection, adaptation, modulation, and progression of virtual reality or gaming when used as a therapeutic exercise modality, and two cases as exemplars. This framework was developed by adapting the steps of theory derivation, whereby concepts and parent theories are brought together to describe a new structure or phenomenon of interest. Specifically, motor learning theory, integrated motor control theory, Gentile's Taxonomy of Tasks, and therapeutic exercise principles were integrated to develop this framework. It incorporates person (body segment), environmental, and task demands; each demand is comprised of realm, category, choice, and continuum parameters as motor training considerations and alternatives for decision-making. This framework: (1) provides structure to guide clinical decisions for effective and safe use of virtual reality or gaming to meet therapeutic goals and requirements, (2) is a concise and organized method to identify, document, and track the therapeutic components of protocols and client progression over time; (3) can facilitate documentation for reimbursement and communication among clinicians; and, (4) structures student learning, and (5) informs research questions and methods.

Effectiveness of Virtual Reality in the Rehabilitation of Motor Function of Patients With Subacute Stroke: A Meta-Analysis

Stroke is a major cause of death and disability in adults. Conventional therapy (CT) has limited effectiveness, and therefore, various virtual reality (VR) rehabilitation programs have been designed. However, their efficacy in regaining motor function in patients with subacute stroke is questionable. Therefore, we conducted this meta-analysis to determine the efficacy of VR, compared to CT, in restoring motor function in this patient population. Up to October 10, 2020, nine electronic databases were searched for relevant articles reporting the effectiveness of VR in regaining motor function in patients with subacute stroke. This search was updated on March 7, 2021, with no additional added articles. The control group included CT, physical therapy, occupational therapy, or a combination of them. Effectiveness is defined as the positive change from baseline values to the last follow-up point. The Cochrane's revised risk-of-bias tool was used to determine the quality of included trials. A metaregression analysis was conducted to determine the effect of "time since last stroke" on reported outcomes. Publication bias and sensitivity analyses were also carried out. A total of 19 studies (17 randomized controlled trials, 1 cohort study, and 1 crossover trial) were included in the qualitative analysis, whereas 16 trials were meta-analyzed. A great improvement in motor function was noted in the VR group, when compared to preintervention values [standardized mean difference (SMD) = 1.14; 95% confidence interval (CI) = 0.77-1.52; I ² = 82%; P < 0.001]. When compared to CT, VR resulted in mild improvement in motor function (SMD = 0.47; 95% CI = 0.22-0.72; I ² = 75%; P < 0.001). However, upon trim-and-fill adjustment, this finding was deemed insignificant (SMD = 0.08; 95% CI = -0.16 to 0.33; I ² = 82.6%; P < 0.001). Ten studies had low risk, five had some concerns, three had high risk, and one had a moderate risk of bias. VR programs can be used jointly with CT for the rehabilitation of the motor function of patients with subacute stroke. However, more studies are still warranted to determine the effectiveness of these interventions in retaining the cognitive function and physical performance of such patients.

Comparison of neuromuscular and cardiovascular exercise intensity and enjoyment between standard of care, off-the-shelf and custom active video games for promotion of physical activity of persons post-stroke

Background

Active video games have been embraced for the rehabilitation of mobility and promotion of physical activity for persons post-stroke. This study seeks to compare carefully matched standard of care stepping activities, off-the-shelf (non-custom) active video games and custom active video games that are either self-paced or game-paced for promoting neuromuscular intensity and accuracy, cardiovascular intensity, enjoyment and perceived effort.

Methods

Fifteen persons (ages 38–72) with mild to moderate severity in the chronic phase post-stroke (average 8 years) participated in a single group counter balanced repeated measures study. Participants were included if they were greater than 6 months post-stroke, who could walk 100 feet without assistance and stand unsupported for three continuous minutes. They were excluded if they had cardiac, musculoskeletal or neurologic conditions that could interfere with repeated stepping and follow instructions. In a single session located in a laboratory setting, participants executed for 8.5 min each: repeated stepping, the Kinect-light race game, two custom stepping games for the Kinect, one was repeated and self-paced and the other was random and game paced. Custom video games were adjusted to the participants stepping volume. Ten-minute rest periods followed the exercise during which time participants rested and completed the PACES an enjoyment questionnaire. Participants were instrumented with a metabolic cart and heart rate sensor for collection of cardiovascular intensity (METs and % of max HR) data. Stepping frequency, accuracy and pattern were acquired via video. Data were analyzed using a RMANOVA and post-hoc comparison with a Holm's/Sidak correction.

Results

Neuromuscular intensity (repetitions) was significantly greater for the off-the-shelf and self-paced custom game, however accuracy was greater for the custom games. Cardiovascular intensity for all activities took place in the moderate intensity exercise band. Enjoyment (measured with a questionnaire and rankings) was greater for the custom active video games and rate of perceived exertion was lower for the custom active video games.

Conclusions

Custom active video games provided comparable intensity but better accuracy, greater enjoyment and less perceived exertion than standard of care stepping activities and a carefully matched off-the-shelf (non-custom) video game. There were no differences between the game-paced and self-paced custom active video games.

Trial registration: NCT04538326.

Virtual Reality in Neurorehabilitation: An Umbrella Review of Meta-Analyses

Neurological disorders are a leading cause of death and disability worldwide. Can virtual reality (VR) based intervention, a novel technology-driven change of paradigm in rehabilitation, reduce impairments, activity limitations, and participation restrictions? This question is directly addressed here for the first time using an umbrella review that assessed the effectiveness and quality of evidence of VR interventions in the physical and cognitive rehabilitation of patients with stroke, traumatic brain injury and cerebral palsy, identified factors that can enhance rehabilitation outcomes and addressed safety concerns. Forty-one meta-analyses were included. The data synthesis found mostly low- or very low-quality evidence that supports the effectiveness of VR interventions. Only a limited number of comparisons were rated as having moderate and high quality of evidence, but overall, results highlight potential benefits of VR for improving the ambulation function of children with cerebral palsy, mobility, balance, upper limb function, and body structure/function and activity of people with stroke, and upper limb function of people with acquired brain injury. Customization of VR systems is one important factor linked with improved outcomes. Most studies do not address safety concerns, as only nine reviews reported adverse effects. The results provide critical recommendations for the design and implementation of future VR programs, trials and systematic reviews, including the need for high quality randomized controlled trials to test principles and mechanisms, in primary studies and in meta-analyses, in order to formulate evidence-based guidelines for designing VR-based rehabilitation interventions.

Aquatic therapy in stroke rehabilitation: systematic review and meta-analysis

The main object of this systematic review and meta-analysis is to collect the available evidence of aquatic therapy in stroke rehabilitation and to investigate the effect of this intervention in supporting stroke recovery. The PubMed, the Cochrane Central Register of Controlled Trials and the PEDro databases were searched from their inception through to 31/05/2020 on randomized controlled trials evaluating the effect of aquatic therapy on stroke recovery. Subjects´ characteristics, methodological aspects, intervention description, and outcomes were extracted. Effect sizes were calculated for each study and outcome. Overall, 28 appropriate studies (N = 961) have been identified. A comparison with no intervention indicates that aquatic therapy is effective in supporting walking, balance, emotional status and health-related quality of life, spasticity, and physiological indicators. In comparison with land-based interventions, aquatic therapy shows superior effectiveness on balance, walking, muscular strength, proprioception, health-related quality of life, physiological indicators, and cardiorespiratory fitness. Only on independence in activities of daily living the land- and water-based exercise induce similar effects. Established concepts of water-based therapy (such as the Halliwick, Ai Chi, Watsu, or Bad Ragaz Ring methods) are the most effective, aquatic treadmill walking is the least effective. The current evidence is insufficient to support this therapy form within evidence-based rehabilitation. However, the available data indicate that this therapy can significantly improve a wide range of stroke-induced disabilities. Future research should devote more attention to this highly potent intervention.

Personalized Virtual Reality Human-Computer Interaction for Psychiatric and Neurological Illnesses: A Dynamically Adaptive Virtual Reality Environment That Changes According to Real-Time Feedback From Electrophysiological Signal Responses

Virtual reality (VR) constitutes an alternative, effective, and increasingly utilized treatment option for people suffering from psychiatric and neurological illnesses. However, the currently available VR simulations provide a predetermined simulative framework that does not take into account the unique personality traits of each individual; this could result in inaccurate, extreme, or unpredictable responses driven by patients who may be overly exposed and in an abrupt manner to the predetermined stimuli, or result in indifferent, almost non-existing, reactions when the stimuli do not affect the patients adequately and thus stronger stimuli are recommended. In this study, we present a VR system that can recognize the individual differences and readjust the VR scenarios during the simulation according to the treatment aims. To investigate and present this dynamically adaptive VR system we employ an Anxiety Disorder condition as a case study, namely arachnophobia. This system consists of distinct anxiety states, aiming to dynamically modify the VR environment in such a way that it can keep the individual within a controlled, and appropriate for the therapy needs, anxiety state, which will be called "desired states" for the study. This happens by adjusting the VR stimulus, in real-time, according to the electrophysiological responses of each individual. These electrophysiological responses are collected by an external electrodermal activity biosensor that serves as a tracker of physiological changes. Thirty-six diagnosed arachnophobic individuals participated in a one-session trial. Participants were divided into two groups, the Experimental Group which was exposed to the proposed real-time adaptive virtual simulation, and the Control Group which was exposed to a pre-recorded static virtual simulation as proposed in the literature. These results demonstrate the proposed system's ability to continuously construct an updated and adapted virtual environment that keeps the users within the appropriately chosen state (higher or lower intensity) for approximately twice the time compared to the pre-recorded static virtual simulation. Thus, such a system can increase the efficiency of VR stimulations for the treatment of central nervous system dysfunctions, as it provides numerically more controlled sessions without unexpected variations.

Head-Mounted Display-Based Therapies for Adults Post-Stroke: A Systematic Review and Meta-Analysis

Immersive virtual reality techniques have been applied to the rehabilitation of patients after stroke, but evidence of its clinical effectiveness is scarce. The present review aims to find studies that evaluate the effects of immersive virtual reality (VR) therapies intended for motor function rehabilitation compared to conventional rehabilitation in people after stroke and make recommendations for future studies. Data from different databases were searched from inception until October 2020. Studies that investigated the effects of immersive VR interventions on post-stroke adult subjects via a head-mounted display (HMD) were included. These studies included a control group that received conventional therapy or another non-immersive VR intervention. The studies reported statistical data for the groups involved in at least the posttest as well as relevant outcomes measuring functional or motor recovery of either lower or upper limbs. Most of the studies found significant improvements in some outcomes after the intervention in favor of the virtual rehabilitation group. Although evidence is limited, immersive VR therapies constitute an interesting tool to improve motor learning when used in conjunction with traditional rehabilitation therapies, providing a non-pharmacological therapeutic pathway for people after stroke.

The effects of virtual reality augmented robot-assisted gait training on dual-task performance and functional measures in chronic stroke: a randomized controlled single-blind trial

BACKGROUND

Many studies have demonstrated positive effects of virtual reality (VR) and robot-assisted gait training (RAGT) on balance, gait skills, functional capacity, active participation, and motivation in stroke patients, previously. However, the effects of VR augmented RAGT on dual-task performance which requires simultaneous use of motor and cognitive parameters have not been investigated.

AIM

To primarily investigate the effects of virtual reality (VR) augmented robot-assisted gait training (RAGT) on dual-task performance and secondarily, functional measurements in chronic stroke patients.

DESIGN

A randomized, single-blind trial.

SETTING

Inpatient rehabilitation center.

POPULATION

The study included 30 chronic stroke patients aged between 40-65 with the level of ≥3 from Functional Ambulation Classification and ≥24 from the Standardized Mini Mental State Examination.

METHODS

Fifteen patients in the study group received VR augmented RAGT and 15 patients in the control group received only RAGT during 12 sessions (six weeks). All patients received neurodevelopmental therapy in addition to their treatments, simultaneously. To evaluate dual-task performance, motor and cognitive tasks were given in addition to the 10 Meter Walk (first motor task), and durations were recorded in seconds. Functional measures such as Functional Gait Assessment, Rivermead Mobility Index, Berg Balance Scale, Fall Activity Scale International, and the Functional Independence Measure for gait, mobility, balance, fear of falling, and independence in daily living activities were also applied, consecutively.

RESULTS

The mean age of the study population was 57.93±5.91. After the treatment, single and dual-task gait speeds and cognitive dual-task performance increased in the study group (P<0.05), while no change was observed in the control group (P>0.05). No significant difference was detected between the groups in terms of all assessments after the treatment (P>0.05).

CONCLUSIONS

This study demonstrated that VR augmented RAGT improved dual-task gait speeds and dual-task performance of chronic stroke patients; however, there were no difference between the two groups after the treatment. Although functional improvements were determined with VR combined RAGT approach, it was not superior to RAGT only treatment.

CLINICAL REHABILITATION IMPACT

The results of current study suggest the simultaneous use of VR as an adjunct therapy method to the functional training to obtain functional gains in ambulant patients with chronic stroke.

Evaluating the effect of immersive virtual reality technology on gait rehabilitation in stroke patients: a study protocol for a randomized controlled trial

BACKGROUND

The high incidence of cerebral apoplexy makes it one of the most important causes of adult disability. Gait disorder is one of the hallmark symptoms in the sequelae of cerebral apoplexy. The recovery of walking ability is critical for improving patients' quality of life. Innovative virtual reality technology has been widely used in post-stroke rehabilitation, whose effectiveness and safety have been widely verified. To date, however, there are few studies evaluating the effect of immersive virtual reality on stroke-related gait rehabilitation. This study outlines the application of immersive VR-assisted rehabilitation for gait rehabilitation of stroke patients for comparative evaluation with traditional rehabilitation.

METHODS

The study describes a prospective, randomized controlled clinical trial. Thirty-six stroke patients will be screened and enrolled as subjects within 1 month of initial stroke and randomized into two groups. The VRT group (n = 18) will receive VR-assisted training (30 min) 5 days/week for 3 weeks. The non-VRT group (n = 18) will receive functional gait rehabilitation training (30 min) 5 days/week for 3 weeks. The primary outcomes and secondary outcomes will be conducted before intervention, 3 weeks after intervention, and 6 months after intervention. The primary outcomes will include time "up & go" test (TUGT). The secondary outcomes will include MMT muscle strength grading standard (MMT), Fugal-Meyer scale (FMA), motor function assessment scale (MAS), improved Barthel index scale (ADL), step with maximum knee angle, total support time, step frequency, step length, pace, and stride length.

DISCUSSION

Virtual reality is an innovative technology with broad applications, current and prospective. Immersive VR-assisted rehabilitation in patients with vivid treatment scenarios in the form of virtual games will stimulate patients' interest through active participation. The feedback of VR games can also provide patients with performance awareness and effect feedback, which could be incentivizing. This study may reveal an improved method of stroke rehabilitation which can be helpful for clinical decision-making and future practice.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900025375 . Registered on 25 August 2019.

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).

Game-based movement facilitates acute priming effect in stroke

OBJECTIVE

Cortical priming is an emerging strategy to enhance motor recovery after stroke, however, limited information exists on the neuromodulatory effects of lower limb movement-based priming to facilitate corticomotor excitability after stroke. In this study, we investigated the feasibility and effectiveness of game-based ankle movement priming using the DIG-I-PRIME™ on corticomotor excitability and motor performance in chronic stroke survivors.

METHODS

Nineteen stroke survivors participated in a 20-min session of game-based priming. A period of rest served as a control for the priming condition. Transcranial magnetic stimulation (TMS) was used to measure corticomotor excitability of the paretic and non-paretic tibialis anterior (TA) muscle representations. Motor performance was quantified by assessing the accuracy to track a sinusoidal target wave with paretic dorsiflexion and plantarflexion.

RESULTS

Ipsilesional corticomotor excitability increased by 25% after game-based movement priming (p = 0.02) while changes were not observed after the control condition. No change in motor performance was noted.

CONCLUSION

Game-based ankle movement priming demonstrated a significant acute priming effect on the ipsilesional lower limb M1. These data provide preliminary evidence for the potential benefits of game-based priming to promote functional recovery after stroke.

Genetic Aspects of Inflammation and Immune Response in Stroke

Genetic determinants play important role in the complex processes of inflammation and immune response in stroke and could be studied in different ways. Inflammation and immunomodulation are associated with repair processes in ischemic stroke, and together with the concept of preconditioning are promising modes of stroke treatment. One of the important aspects to be considered in the recovery of patients after the stroke is a genetic predisposition, which has been studied extensively. Polymorphisms in a number of candidate genes, such as IL-6, BDNF, COX2, CYPC19, and GPIIIa could be associated with stroke outcome and recovery. Recent GWAS studies pointed to the variant in genesPATJ and LOC as new genetic markers of long term outcome. Epigenetic regulation of immune response in stroke is also important, with mechanisms of histone modifications, DNA methylation, and activity of non-coding RNAs. These complex processes are changing from acute phase over the repair to establishing homeostasis or to provoke exaggerated reaction and death. Pharmacogenetics and pharmacogenomics of stroke cures might also be evaluated in the context of immuno-inflammation and brain plasticity. Potential novel genetic treatment modalities are challenged but still in the early phase of the investigation.

Serum BDNF's Role as a Biomarker for Motor Training in the Context of AR-Based Rehabilitation after Ischemic Stroke

BACKGROUND

brain-derived neurotrophic factor (BDNF) may play a role during neurorehabilitation following ischemic stroke. This study aimed to elucidate the possible role of BDNF during early recovery from ischemic stroke assisted by motor training.

METHODS

fifty patients were included after acute recovery from ischemic stroke: 21 first received classical rehabilitation followed by 'motor rehabilitation using motion sensors and augmented reality' (AR-rehabilitation), 14 only received AR-rehabilitation, and 15 were only observed. Serum BDNF levels were measured on the first day of stroke, on the 14th day, before AR-based rehabilitation (median, 45th day), and after the AR-based rehabilitation (median, 82nd day). Motor impairment was quantified clinically using the Fugl-Meyer scale (FMA); functional disability and activities of daily living (ADL) were measured using the Modified Rankin Scale (mRS). For comparison, serum BDNF was measured in 50 healthy individuals.

RESULTS

BDNF levels were found to significantly increase during the phase with AR-based rehabilitation. The pattern of the sequentially measured BDNF levels was similar in the treated patients. Untreated patients had significantly lower BDNF levels at the endpoint.

CONCLUSIONS

the fluctuations of BDNF levels are not consistently related to motor improvement but seem to react to active treatment. Without active rehabilitation treatment, BDNF tends to decrease.

VIDA-Nursing v1.0: immersive virtual reality in vacuum blood collection among adults

OBJECTIVE

to develop and validate the first immersive virtual reality simulation addressing vacuum blood collection in adult patients - VIDA-Nursing v1.0.

METHOD

methodological study to validate 14 steps of the vacuum blood collection procedure in adults, designed to develop the immersive virtual reality simulator VIDA-Nursing v1.0. It was assessed by 15 health workers and 15 nursing undergraduate students in terms of visual, interactive, movement simulation reality, teaching and user-friendly aspects.

RESULTS

the workers considered 79.6% of the items to be valid, while the students considered 66.7% of the items valid; most of the demands can be implemented in the system by improving future versions.

CONCLUSION

the simulator was considered a promising and innovative tool to teach vacuum blood collection in adults as it can be combined with other resources currently used to introduce this topic and technique in the education of undergraduate nursing students.

[Poststroke cognitive impairment and the possibility of its nonpharmacological treatment with vestibular stimulation based on biological feedback to supporting reaction]

Cognitive impairment is common in poststroke patients. Today in rehabilitation programs the specialists use the vestibular stimulation including biological feedback to supporting reaction for treatment poststroke cognitive impairment. These studies show the relationship of vestibular function with memory, attention, spatial orientation, navigation, mental representation of three-dimensional space and other cognitive functions. It makes possible to build rehabilitation programs for patients with stroke.