Standards of Virtual Reality Application in Balance Training Programs in Clinical Practice: A Systematic Review

A machine learning approach to evaluate the impact of virtual balance/cognitive training on fall risk in older women

Introduction

Novel technologies based on virtual reality (VR) are creating attractive virtual environments with high ecological value, used both in basic/clinical neuroscience and modern medical practice. The study aimed to evaluate the effects of VR-based training in an elderly population.

Materials and methods

The study included 36 women over the age of 60, who were randomly divided into two groups subjected to balance-strength and balance-cognitive training. The research applied both conventional clinical tests, such as (a) the Timed Up and Go test, (b) the five-times sit-to-stand test, and (c) the posturographic exam with the Romberg test with eyes open and closed. Training in both groups was conducted for 10 sessions and embraced exercises on a bicycle ergometer and exercises using non-immersive VR created by the ActivLife platform. Machine learning methods with a k-nearest neighbors classifier, which are very effective and popular, were proposed to statistically evaluate the differences in training effects in the two groups.

Results and conclusion

The study showed that training using VR brought beneficial improvement in clinical tests and changes in the pattern of posturographic trajectories were observed. An important finding of the research was a statistically significant reduction in the risk of falls in the study population. The use of virtual environments in exercise/training has great potential in promoting healthy aging and preventing balance loss and falls among seniors.

Comparison of Nonimmersive Virtual Reality and Task-Oriented Circuit Training on Gait, Balance and Cognition Among Elderly Population: A Single-Blind Randomized Control Trial

Purpose: The purpose of this study was to determine the effects of nonimmersive virtual reality (VR) and task-oriented circuit training on gait, balance, cognitive domains, and quality of life among the elderly population. Methods: This is a single-blind randomized control trial in which 28 elderly individuals between 60 and 75 years were selected. The participants were divided into two groups, task-oriented circuit training and the other receiving nonimmersive VR treatment, with 14 participants in each group. To analyze the effects of both training on balance and gait time up and go test (TUGT), dynamic gait index (DGI), measures were used and for cognitive domains Montreal cognitive assessment (MoCA) scale was used. Short form 12 (SF-12) (along with two domains, Physical Component Summary and Mental Component Summary) was used for the measurement of quality of life. The treatment duration was 8 weeks for both groups. Both the pre-test and post-test readings were analyzed and compared. Results: The mean age of participants was 66.91 ± 3.79 years. Within-group comparison between the pre-test and post-test indicated that significant differences (P < 0.05) existed in all the outcome measures (TUGT, DGI, MoCA, and SF-12) in both groups. However, between-group comparison, significant differences were only found in TUGT and DGI in nonimmersive VR group. Conclusion: This study concluded that both interventions nonimmersive VR and task-oriented circuit training were beneficial for improving balance, gait, quality of life, and cognitive domains like memory, attention spans, executive functions, and so on in elderly population. However nonimmersive virtual reality training is a more effective, feasible, and safe alternative and can be proposed as a form of fall prevention exercise for the older adults. ClinicalTrials.gov Identifier: NCT05021432.

The effect of telerehabilitation on balance in stroke patients: is it more effective than the traditional rehabilitation model? A meta-analysis of randomized controlled trials published during the COVID-19 pandemic

Objective

Telerehabilitation and telemedicine have gradually gained popularity. In 2019, the outbreak of COVID-19 started in Wuhan and then spread across the world. To date, most countries have opted to coexist with the virus. However, patients, especially those who have suffered a stroke, should take measures to avoid being infected with any disease as much as possible since any infectious disease can lead to adverse events for them. Telerehabilitation can be beneficial to stroke patients as they are less likely to be infected by the virus. In recent years, several studies on telerehabilitation have been conducted globally. This meta-analysis aimed to investigate the effects of telerehabilitation on the balance ability of stroke patients, compare the efficacy of conventional rehabilitation with telerehabilitation, explore the characteristics of telerehabilitation and conventional rehabilitation, and provide recommendations for rehabilitation programs in the context of the global pandemic.

Methods

We searched Pubmed, Embase, the Web of Science, and The Cochrane Library databases from 1 January 2020 to 31 December 2022 for randomized controlled trials published in English that evaluated the improvement of balance function in stroke patients after telerehabilitation and compared the differences between telerehabilitation (TR) and conventional rehabilitation (CR). The random-effects model was utilized to calculate mean differences (MDs) with 95% confidence intervals (CIs) to estimate intervention effects. Statistical heterogeneity was assessed according to the I² values. The risk of bias was measured using the Cochrane risk-of-bias assessment tool.

Results

We included nine studies in the system evaluation, all of which were included in the pooled analysis. All outcomes in the experimental and control groups improved over time. The comparison between groups concluded that people who received the telerehabilitation intervention had a significant improvement in the Berg Balance Scale (MD = 2.80; 95% CI 0.61, 4.98, P < 0.05, I2 = 51.90%) and the Fugl-Meyer Assessment (MD = 8.12; 95% CI 6.35, 9.88, P < 0.05, I2 = 0) compared to controls. The Timed Up and Go test (MD = -4.59; 95% CI -5.93, -.25, P < 0.05, I² = 0) and Tinetti Performance-Oriented Mobility Assessment-Balance (MD = 2.50; 95% CI 0.39, 4.61, P < 0.05) scored better in the control group than in the experimental group. There were no significant differences in other outcomes between the two groups.

Conclusion

Studies on changes in medical conditions during the COVID-19 pandemic also demonstrated that, for stroke patients, telerehabilitation achieves similar effects as the conventional rehabilitation model and can act as a continuation of the conventional rehabilitation model. Owing to the different equipment and intervention programs of telerehabilitation, its curative effect on the static balance and reactive balance of stroke patients may be different. Currently, telerehabilitation may be more conducive to the rehabilitation of patients' static balance abilities, while conventional rehabilitation is more effective for the rehabilitation of patients' reactive balance. Therefore, further studies are needed for investigating the difference in efficacy between varied devices and telerehabilitation programs. Further research is needed on static and reactive balance. In addition, such research should have a large body of literature and a large sample size to support more definitive findings based on the context of the COVID-19 pandemic.

Systematic review registration

CRD42023389456.

Virtual reality simulation of panoramic radiographic anatomy for dental students

PURPOSE

This work aimed to utilize virtual reality (VR) in dental radiographic anatomical interpretation in junior dental students and test if it can enhance student learning, engagement, and performance.

METHODS

VR software for panoramic anatomy was developed. Sixty-nine first-year dental students were divided into a control group (lecture-based) and an experimental group (VR) to learn panoramic radiographic anatomy. Both groups were then tested on knowledge via a 20-question quiz. Student feedback on VR experience was collected via an online survey.

RESULTS

There was a statistically significant difference between lecture-based and VR students in the correct identification of anatomical landmarks. Lecture-based students scored higher in identifying the ear lobe, hyoid bone, condylar neck, and external oblique ridge, whereas VR students scored higher in identifying zygoma (Chi-squared test, p < 0.005). The VR group reported high evaluation on all perception items of the online feedback survey on their experience (Student t-test, p < 0.005).

CONCLUSIONS

Lecture-based students generally showed better performance in panoramic radiographic anatomy. Several structures were not correctly identified in both groups of novice students. The positive feedback of VR experience encourages future implementation in education to augment conventional methods of radiographic anatomy in dentistry with considerations to repeated exposures throughout undergraduate dental education.

Impact of Virtual Reality Cognitive and Motor Exercises on Brain Health

Innovative technologies of the 21st century have an extremely significant impact on all activities of modern humans. Among them, virtual reality (VR) offers great opportunities for scientific research and public health. The results of research to date both demonstrate the beneficial effects of using virtual worlds, and indicate undesirable effects on bodily functions. This review presents interesting recent findings related to training/exercise in virtual environments and its impact on cognitive and motor functions. It also highlights the importance of VR as an effective tool for assessing and diagnosing these functions both in research and modern medical practice. The findings point to the enormous future potential of these rapidly developing innovative technologies. Of particular importance are applications of virtual reality in basic and clinical neuroscience.

Trunk Biomechanics in Individuals with Knee Disorders: A Systematic Review with Evidence Gap Map and Meta-analysis

BACKGROUND

The trunk is the foundation for transfer and dissipation of forces throughout the lower extremity kinetic chain. Individuals with knee disorders may employ trunk biomechanical adaptations to accommodate forces at the knee or compensate for muscle weakness. This systematic review aimed to synthesize the literature comparing trunk biomechanics between individuals with knee disorders and injury-free controls.

METHODS

Five databases were searched from inception to January 2022. Observational studies comparing trunk kinematics or kinetics during weight-bearing tasks (e.g., stair negotiation, walking, running, landings) between individuals with knee disorders and controls were included. Meta-analyses for each knee disorder were performed. Outcome-level certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE), and evidence gap maps were created.

RESULTS

A total of 81 studies investigating trunk biomechanics across six different knee disorders were included (i.e., knee osteoarthritis [OA], total knee arthroplasty [TKA], patellofemoral pain [PFP], patellar tendinopathy [PT], anterior cruciate ligament deficiency [ACLD], and anterior cruciate ligament reconstruction [ACLR]). Individuals with knee OA presented greater trunk flexion during squatting (SMD 0.88, 95% CI 0.58-1.18) and stepping tasks (SMD 0.56, 95% CI 0.13-.99); ipsilateral and contralateral trunk lean during walking (SMD 1.36; 95% CI 0.60-2.11) and sit-to-stand (SMD 1.49; 95% CI 0.90-2.08), respectively. Greater trunk flexion during landing tasks in individuals with PFP (SMD 0.56; 95% CI 0.01-1.12) or ACLR (SMD 0.48; 95% CI 0.21-.75) and greater ipsilateral trunk lean during single-leg squat in individuals with PFP (SMD 1.01; 95% CI 0.33-1.70) were also identified. No alterations in trunk kinematics of individuals with TKA were identified. Evidence gap maps outlined the lack of investigations for individuals with PT or ACLD, as well as for trunk kinetics across knee disorders.

CONCLUSION

Individuals with knee OA, PFP, or ACLR present with altered trunk kinematics in the sagittal and frontal planes. The findings of this review support the assessment of trunk biomechanics in these individuals in order to identify possible targets for rehabilitation and avoidance strategies.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019129257.

Eight-week virtual reality training improves lower extremity muscle strength but not balance in adolescents with intellectual disability: A randomized controlled trial

Purpose: This study aims to assess the effects of 8-week virtual reality (VR) training on balance and lower extremity muscle strength in adolescents with intellectual disability (ID).

Methods: Thirty adolescents with intellectual disability were randomly divided into the virtual reality group and control group. The participants in the virtual reality group and the control group received the virtual reality training and the physical education (PE) course, respectively, for 8 weeks. The Berg Balance Scale (BBS), Timed Up and Go (TUG) test and lower extremity muscle strength were measured before and after the training.

Results: The between-group results showed that the participants in the virtual reality group increased the muscle strength of hip flexors (p &lt; 0.001), hip extensors (p = 0.002), hip abductors (p &lt; 0.001), knee flexors (p &lt; 0.001), knee extensors (p = 0.002) and ankle plantar flexors (p = 0.042) significantly after training, compared to the control group. However, no significant improvement was found in the berg balance scale and timed up and go scores between the virtual reality group and control group after training (p &gt; 0.05). The within-group results showed that the strength of all the muscle groups significantly increased after training in the virtual reality group (p &lt; 0.05) compared to the baseline. However, no significant difference was found in the muscle strength in the control group before and after training. The within-group berg balance scale and timed up and go scores showed no significant improvements in both groups.

Conclusion: Virtual reality training intervention might be effective in improving the lower extremity muscle strength, but no significant improvement was found on balance ability in adolescents with intellectual disability.

The Effects of Acute Virtual Reality Exergaming on Mood and Executive Function: Exploratory Crossover Trial

Background

Virtual reality (VR) exergaming is a new intervention strategy to help humans engage in physical activity to enhance mood. VR exergaming may improve both mood and executive function by acting on the prefrontal cortex, expanding the potential benefits. However, the impact of VR exergaming on executive function has not been fully investigated, and associated intervention strategies have not yet been established.

Objective

This study aims to investigate the effects of 10 minutes of VR exergaming on mood and executive function.

Methods

A total of 12 participants played the exergame “FitXR” under 3 conditions: (1) a VR exergame condition (ie, exercise with a head-mounted display condition [VR-EX]) in which they played using a head-mounted display, (2) playing the exergame in front of a flat display (2D-EX), and (3) a resting condition in which they sat in a chair. The color-word Stroop task (CWST), which assesses executive function; the short form of the Profile of Mood States second edition (POMS2); and the short form of the Two-Dimensional Mood Scale (TDMS), which assess mood, were administered before and after the exercise or rest conditions.

Results

The VR-EX condition increased the POMS2 vigor activity score (rest and VR-EX: t₁₁=3.69, P=.003) as well as the TDMS arousal (rest vs 2D-EX: t₁₁=5.34, P<.001; rest vs VR-EX: t₁₁=5.99, P<.001; 2D-EX vs VR-EX: t₁₁=3.02, P=.01) and vitality scores (rest vs 2D-EX: t₁₁=3.74, P=.007; rest vs VR-EX: t₁₁=4.84, P=.002; 2D-EX vs VR-EX: t₁₁=3.53, P=.006), suggesting that VR exergaming enhanced mood. Conversely, there was no effect on CWST performance in either the 2D-EX or VR-EX conditions. Interestingly, the VR-EX condition showed a significant positive correlation between changes in CWST arousal and reaction time (r=0.58, P=.046). This suggests that the effect of exergaming on improving executive function may disappear under an excessively increased arousal level in VR exergaming.

Conclusions

Our findings showed that 10 minutes of VR exergaming enhanced mood but did not affect executive function. This suggests that some VR content may increase cognitive demands, leading to psychological fatigue and cognitive decline as an individual approaches the limits of available attentional capacity. Future research must examine the combination of exercise and VR that enhances both brain function and mood.

Effectiveness of Early Rehabilitation with Exergaming in Virtual Reality on Gait in Patients after Total Knee Replacement

Total knee replacement (TKR) is the treatment of choice for advanced stages of osteoarthritis but it requires good postoperative rehabilitation. This study aimed to assess the effectiveness of exercises using virtual reality to improve gait parameters in patients after TKR. Fifty-nine patients 7−14 days after TKR surgery were divided into a study group (VRG, n = 38) and a control group (CG, n = 21). Both groups underwent the same 4-week rehabilitation protocol. The VRG group had 12 additional nonimmersive virtual reality game sessions on the Virtual Balance Clinic prototype system at 30 min each, focusing on gait and balance improvement. Spatiotemporal, force and foot plantar pressure parameters were collected on an instrumented treadmill during a 30 s walk. The most significant improvement was in the symmetry indices of forefoot force, maximum forefoot force, loading response time, and preswing time (p < 0.05) in both groups. Gait speed increased by 31.25% and 44% in the VRG and CG groups, respectively (p < 0.005). However, the extra exergaming sessions did not significantly improve rehabilitation outcomes. Therefore, additional VR training does not improve gait better than standard rehabilitation alone, but the improvement of gait, especially its symmetry, is significant within the first six weeks after surgery.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Fitness Apps, Live Streaming Workout Classes, and Virtual Reality Fitness for Physical Activity During the COVID-19 Lockdown: An Empirical Study

Background

Physical activity is an essential need of the human body that helps improve the physical fitness of an individual and creates a positive impact on overall wellbeing. Smartphone applications play an essential role in providing several benefits to consumers by offering various capabilities in terms of health and fitness.COVID-19 preventive measures shut down public places, and people cannot go to the gym and parks for physical activity. Smart applications for physical activity are an effective way to keep active while staying at home.

Objective

The objective of the present study was to assess the mediating role of the e-platforms physical activity among the Chinese people in China during the COVID-19 lockdown.

Method

The participants in this study were Chinese citizens living in home isolation during the early stages of the epidemic in China. The primary data was collected via an online survey using a convenience sample strategy in accordance with the study purpose. The collected data were cleaned by using the SPSS-25 statistical software. SmartPLS 3.0 software was used to investigate the suggested study framework utilizing the structural equation modeling technique.

Results

Descriptive statistics shows that the ratio of gender includes 49% (n = 2,626) male and 51% females in the entire sample. SEM results show that all hypotheses (H1: β = 0.497, T = 43.068, P = <0.001; H2: β = 0.498, T = 41.078, P = <0.001; H3: β = 0.498, T = 41.078, P = <0.001; H4: β = 0.471, T = 39.103, P = <0.001; H5: β = 0.468, T = 42.633, P = <0.001; H6: β = 0.251, T = 11.212, P = <0.001; H7: β = 0.367, T = 16.032, P = <0.001; H8: β = 0.170, T = 13.750, P = <0.001; H9: β = 0.125, T = 10.604, P = <0.001; H10: β = 0.173, T = 14.842, P = <0.001) were statistically confirmed.

Conclusion

In COVID-19, when there are limited physical activity resources, smart applications play an essential role as an alternative to gyms and change people's perspective regarding the adoption of health and fitness. Smart applications have made exercise and physical activity accessible and convenient to adopt.

Sinusoidal Optic Flow Perturbations Reduce Transient but Not Continuous Postural Stability: A Virtual Reality-Based Study

Optic flow perturbations induced by virtual reality (VR) are increasingly used in the rehabilitation of postural control and gait. Here, VR offers the possibility to decouple the visual from the somatosensory and vestibular system. By this means, it enables training under conflicting sensorimotor stimulation that creates additional demands on sensory reweighting and balance control. Even though current VR-interventions still lack a well-defined standardized metric to generate optic flow perturbations that can challenge balance in a repeatable manner, continuous oscillations of the VR are typically used as a rehabilitation tool. We therefore investigated if continuous sensory conflicts induced by optic flow perturbations can challenge the postural system sustainably. Eighteen young adults (m = 8, f = 10, age = 24.1 ± 2.0 yrs) were recruited for the study. The VR was provided using a state-of-the-art head-mounted display including the virtual replica of the real environment. After familiarization in quiet stance without and with VR, bipedal balance was perturbed by sinusoidal rotations of the visual scenery in the sagittal plane with an amplitude of 8° and a frequency of 0.2 Hz. Postural stability was quantified by mean center of mass speed derived from 3D-kinematics. A rmANOVA found increased postural instability only during the first perturbation cycle, i.e., the first 5 s. Succeeding the first perturbation cycle, visual afferents were downregulated to reduce the destabilizing influence of the sensory conflicts. In essence, only the transient beginning of sinusoidal oscillation alters balance compared to quiet standing. Therefore, continuous sinusoidal optic flow perturbations appear to be not suitable for balance training as they cannot trigger persisting sensory conflicts and hence challenge the postural system sustainably. Our study provides rationale for using unexpected and discrete optic flow perturbation paradigms to induce sustainable sensory conflicts.

Effect of virtual reality rehabilitation on functional outcomes for return-to-work patients with Parkinson's disease: An umbrella review of systematic reviews

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disease characterized by loss of substantia nigra neurons with deficiency of dopamine. The main symptoms are tremor, rigidity and bradykinesia. Rehabilitation has an important role in the treatment of this condition and virtual reality (VR) is one of the most recent tools.

OBJECTIVE

The purpose of this umbrella review is to evaluate the effectiveness of VR systems on gait control for return to work in patients with PD.

METHODS

The electronic search, for reviews and meta-analysis studies that investigated the effectiveness of VR on gait control in PD patients, was performed through December 2021 using the following databases: PubMed, Scopus, PEDro, and Google Scholar. Mesh terms used were: Job integration/reintegration OR return-to-work AND Parkinson's disease AND virtual reality OR exergame. No limit on the year of publication of the article was used.

CONCLUSIONS

A total of 14 articles were included in our analysis. The included evidence shows a stride length improvement in patients treated with VR compared to conventional active treatments. No difference was found in walking speed. Also, the included articles show an improvement on various measures of balance, motor function and severity of PD motor symptoms. In addition, the literature shows an improvement in the quality of life and neuropsychiatric symptoms in patients undergoing VR rehabilitation training.

RESULTS

he results of our study suggest that VR rehabilitation improves gait performance, particularly stride length, thus being able to provide an improvement in the quality of life and a more effective return to work training in patients with PD.

Construction and Application of Virtual Reality-Based Sports Rehabilitation Training Program

This paper adopts virtual reality technology to conduct in-depth research and analysis on sports rehabilitation training, designs a corresponding sports rehabilitation training program, and applies it to practice. An AR algorithm based on dynamic target tracking under VSLAM is proposed. The algorithm can effectively reject dynamic targets in static scenes while ensuring that the virtual objects registered based on dynamic template target tracking are still in the world coordinate system of VSLAM. To facilitate patients' hand function rehabilitation training, this paper uses OpenPose for 2D gesture pose recognition, combines camera pose information and depth information provided by VSLAM to map key points of the hand into the world coordinate system, and then completes the interaction by collision detection algorithm. The virtual interaction module is implemented in this paper to meet the demand for multiuser off-site interaction in virtual training. This paper uses the Unity3D software and Photon Server server to create a VR virtual scene and design a user interaction mechanism to realize a system that supports multiple users to train together online, which effectively extends the application scope of the VR training system. The module utilizes Unity3D's VR development capabilities to develop VR virtual basketball gym scenes and single-player offline interaction mechanisms such as virtual user single shooter and shooter; then, Photon Server is used to design and implement a multiuser remote login system and a multiuser interpass mechanism, thus achieving the effect of multiplayer remote online interaction in the same VR space. Finally, the proposed module was validated, and the results proved the effectiveness of the sports rehabilitation training program.

Effect of home-based virtual reality training and telerehabilitation on balance in individuals with Parkinson disease, multiple sclerosis, and stroke: a systematic review and meta-analysis

OBJECTIVE

In the last decade, there is a growing interest in the use of virtual reality for rehabilitation in clinical and home settings. The aim of this systematic review is to do a summary of the current evidence on the effect of home-based virtual reality training and telerehabilitation on postural balance in individuals with central neurological disorders.

METHODS

Literature was searched in PubMed, Web of Science, PEDro, ScienceDirect, and MEDLINE. Randomized controlled trials (RCTs) evaluating the effect of home-based virtual reality (VR) training and telerehabilitation (TR) on postural balance in patients with Parkinson's disease, Multiple sclerosis or stroke. Studies were imported to EndNote and Excel to perform two screening phases by four reviewers. Risk of bias was assessed using PEDro scale and Cochrane assessment tool for risk of bias. Synthesis of the data on comparative outcomes was performed using RevMan software.

RESULTS

Seven RCTs were included, with all three pathologies represented. VR and TR consisted of a training device (e.g., Nintendo Wii or Xbox 360) and a monitoring device (e.g., Skype or Microsoft Kinect). Five studies used the Berg Balance Scale (BBS) for measuring postural balance. Across studies, there was an improvement in BBS scores over time in both experimental and control groups, and the effect remained at follow-up for both groups. However, there was no significant difference between  groups post-intervention (MD = 0.74, p = 0.45).

CONCLUSION

Home-based VR and TR can be used as prolongation to conventional therapy.

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

BACKGROUND

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

RESEARCH QUESTION

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

Virtual Reality Fitness (VRF) for Behavior Management During the COVID-19 Pandemic: A Mediation Analysis Approach

Background

During the COVID-19 pandemic, cellphone health apps and virtual reality fitness for treating neurological disorders such as Parkinson’s were beneficial. Virtual reality has been used to treat PTSD, depression, anxieties, dementia, ADHD, dyslexia, and pain control in various settings. Virtual reality exercise has been studied for its effects on biological, mental, rehabilitation, behavior, and attitude management.

Purpose

This research aimed to find out the role of virtual reality fitness (VRF) for behavior management during the COVID-19 pandemic concerning the demographic characteristics of the study participants and the use of fitness and health apps.

Methods

The population for the current study was Chinese residents across China who were in home isolation during the early pandemic in China. According to the study objective, a convenience sampling method was used to collect the primary data through an online survey. SPSS-25 statistical software was used to analyze the demographic information and clean and prepare the data to test all proposed hypotheses. The proposed research framework was examined using the structural equation modeling (SEM) approach through SmartPLS 3.0 software.

Results

The structural equation model analysis shows that all the proposed hypotheses (H1: β = 0.137, t = 10.454, p = <0.000; H2: β = 0.256, t = 16.824, p = <0.000; H3: β = 0.418, t = 27.827, p = <0.000; H4: β = 0.133, t = 8.913, p = <0.000; H5: β = 0.076, t = 4.717, p = <0.000; H6: β = 0.162, t = 10.532, p = <0.000; H7: β = 0.384, t = 26.645, p = <0.000) are confirmed.

Conclusion

Fitness and health apps with virtual reality fitness play a substantial role in improving the overall quality of life and positively influencing behavior and attitude.

A Novel Virtual Reality Training Strategy for Poststroke Patients: A Randomized Clinical Trial

Stroke patients suffer impairments including sensory, motor, visual, and cognitive areas, as well as gait and balance manifestations making activities of daily living difficult. In such conditions, virtual reality training can be a potential rehabilitation tool in comparison to conventional physical therapy to cater to the burden of this disability; hence, this randomized clinical trial compared the effects of virtual reality training and conventional physical therapy on balance and lower extremity function in stroke patients. The sample of 68 poststroke participants from Kanaan Physical Therapy and Spine Clinic, Lahore, Pakistan, were divided into N = 34 cases each using the lottery method with one group given virtual reality training and the other received conventional physical therapy. Each group received 60 minutes intervention, 3 days per week for 6 weeks. The Berg balance scale and the Fugl-Meyer assessment-lower extremity scale were employed for data collection preintervention, immediate postintervention, and 6 weeks postintervention. The statistically significant differences between virtual reality and conventional physical therapy groups for the Berg Balance score (p < 0.001), Fugl-Meyer assessment (FMA)-lower extremity domains of FMA-motor function (p < 0.001), FMA-joint pain, and joint range (p < 0.001); however, there is no significant difference (p=0.202) for time vs. group interaction and significant (p < 0.001) for the time main effect for FMA sensation. Hence, virtual reality training is more effective to restore balance and lower extremity function compared to conventional physical therapy in stroke patients. The results of the study have significant implications for the clinicians with better case management enhancing quality of life of patients along with the dearth of local literature, thus providing base for future research from a developing country's perspective.

Parkinson's disease

Parkinson's disease is a recognisable clinical syndrome with a range of causes and clinical presentations. Parkinson's disease represents a fast-growing neurodegenerative condition; the rising prevalence worldwide resembles the many characteristics typically observed during a pandemic, except for an infectious cause. In most populations, 3-5% of Parkinson's disease is explained by genetic causes linked to known Parkinson's disease genes, thus representing monogenic Parkinson's disease, whereas 90 genetic risk variants collectively explain 16-36% of the heritable risk of non-monogenic Parkinson's disease. Additional causal associations include having a relative with Parkinson's disease or tremor, constipation, and being a non-smoker, each at least doubling the risk of Parkinson's disease. The diagnosis is clinically based; ancillary testing is reserved for people with an atypical presentation. Current criteria define Parkinson's disease as the presence of bradykinesia combined with either rest tremor, rigidity, or both. However, the clinical presentation is multifaceted and includes many non-motor symptoms. Prognostic counselling is guided by awareness of disease subtypes. Clinically manifest Parkinson's disease is preceded by a potentially long prodromal period. Presently, establishment of prodromal symptoms has no clinical implications other than symptom suppression, although recognition of prodromal parkinsonism will probably have consequences when disease-modifying treatments become available. Treatment goals vary from person to person, emphasising the need for personalised management. There is no reason to postpone symptomatic treatment in people developing disability due to Parkinson's disease. Levodopa is the most common medication used as first-line therapy. Optimal management should start at diagnosis and requires a multidisciplinary team approach, including a growing repertoire of non-pharmacological interventions. At present, no therapy can slow down or arrest the progression of Parkinson's disease, but informed by new insights in genetic causes and mechanisms of neuronal death, several promising strategies are being tested for disease-modifying potential. With the perspective of people with Parkinson's disease as a so-called red thread throughout this Seminar, we will show how personalised management of Parkinson's disease can be optimised.

Biomechanical measures of balance after balance-based exergaming training dedicated for patients with Parkinson's disease

INTRODUCTION

Although previous studies have contributed to our understanding of the effects of implementing the virtual reality as a rehabilitation tool in patients with Parkinson's disease (PD), additional research is needed to examine the effects of applying balance-based exergaming training on quantitative biomechanical measures of balance.

RESEARCH QUESTION

To investigate the effects of balance-based conventional and exergaming training on posture parameters.

METHODS

The study involved 24 patients with PD (Hoehn and Yahr stages II-III).Participants underwent twelve training sessions during the 4-week training period. The experimental group (n=12) was trained with a custom-made exergaming balance based training system, the control group (n=12) underwent a conventional balance training. All objective outcomes were measured before intervention and the day after completion of training program. Postural stability was assessed using the quiet standing test, dynamic balance was assessed using limits of stability (LOS) and functional balance (FBT) tests.

RESULTS

After training, participants in both groups showed significantly better results in static balance performance. However, only exergaming training significantly improved LOS performance (higher values of Range of forward lean (p = 0.039, d_z = 0.67) and leaning rate (p=0.007, d_z=0.96). Also FBT test improved significantly only in experimental group (decrease in time to target hit (p=0.02, d_z=0.76) and significant increase of average COP velocity (p=0.008, d_z=0.93).

CONCLUSION

This study found that exergaming training created for patients with PD enhanced static and dynamic balance whereas conventional balance training improved static balance. Posturography is sensitive enough to reveal differential effects of training for both groups. These findings support the inclusion of our exergaming training in the exercise program for participants with PD.

A novel virtual reality approach for functional lateralization in healthy adults

Functional lateralization relates to a natural asymmetry in the dominance right or left body side, and is a fundamental principle of the brain. The hemispheres of the brain control the contralateral body side, and show subtle, yet striking, anatomical asymmetries and functional lateralization. Innovative technologies, including Virtual Reality (VR), are entering the areas of experimental research, modeling and simulation related to the study of lateralization, with new perspectives of different applications in modern medical practice. Researchers/clinicians note that there are fewer VR studies with healthy participants, and which are important in evaluating/interpreting clinical outcomes, and testing the usefulness, limitations, and sensitivity of VR. The presented influence of the domination of upper/lower limbs on the performance of VR exercises was studied in healthy right-handed adults. Virtual testing sessions were performed independently with both/ dominant/ non-dominant hands, and the similar VR sessions were conduced on a Wii Balance Board (WBB) with the choice of body side, at different levels of the difficulty. The obtained results are consistent with other studies which show that cognitive-motor training in VR with the WBB platform is a very sensitive and promising tool for recognizing/assessing functional asymmetries of the right-left body side not only in disturbed lateralization, but also in the test training of healthy subjects.

Mixed Assessment of Virtual Serious Games Applied in Architectural and Urban Design Education

The creation and usage of serious games on virtual reality (VR) and/or interactive platforms for the teaching of architecture, construction, urban planning, and other derived areas, such as security and risk prevention, require design processes, studies, and research that lead to further consolidation expansion. In that sense, this paper presents two main aims developed: the improvement of a virtual navigation system through the results of previous user studies and mixed research (quantitative and qualitative) improved based on the user perception for educational and professional uses. The VR system used is based on Unreal Engine programming of the HTC Vive sensor. This study is related to the GAME4City 3.0 and a broader project focused on gamified visualization and its educational uses in architectural and urban projects. The results reflect great interest, good usability, and high motivation for further usage for all types of users. However, an apparent resistance to deepen its use continues to be perceived in academia. Based on the research results, weak points of educational gamified systems have been identified, and the main differences and needs in user profiles’ function. With these data, progress regarding implementing this kind of system at the teaching and professional levels must be pursued.

Assessment of the Effectiveness of Rehabilitation after Total Knee Replacement Surgery Using Sample Entropy and Classical Measures of Body Balance

Exercises in virtual reality (VR) have recently become a popular form of rehabilitation and are reported to be more effective than a standard rehabilitation protocol alone. The aim of this study was to assess the efficacy of adjunct VR training in improving postural control in patients after total knee replacement surgery (TKR). Forty-two patients within 7-14 days of TKR were enrolled and divided into a VR group and a control group (C). The C group underwent standard postoperative rehabilitation. The VR group additionally attended twelve 30-min exercise sessions using the Virtual Balance Clinic prototype system. Balance was assessed on the AMTI plate in bipedal standing with and without visual feedback before and after the four-week rehabilitation. Linear measures and sample entropy of CoP data were analyzed. After four weeks of rehabilitation, a significant reduction in parameters in the sagittal plane and ellipse area was noted while the eyes remained open. Regression analysis showed that sample entropy depended on sex, body weight, visual feedback and age. Based on the sample entropy results, it was concluded that the complexity of the body reaction had not improved. The standing-with-eyes-closed test activates automatic balance mechanisms and offers better possibilities as a diagnostic tool.

The Use of Frequency Analysis as a Complementary and Explanatory Element for Time Domain Analysis in Measurements of the Ability to Maintain Balance

Assessment of human balance is one of the most common diagnostic tests, both in medical applications and during sports training. Many new methods of measuring are introduced in these studies; however, the analysis of results is still carried out mainly based on the values determined in the time domain - the average COP speed or the ellipse field of the prediction. The aim of the current work is to present the possibilities for the practical application of frequency analyses in assessment of the ability to maintain body balance as a method supplementing standard analyses. As part of the study, measurements of the ability to maintain balance in sensory conflict conditions introduced in the form of an oscillating, three-dimensional, virtual scenery were carried out. 27 healthy volunteers (13 women and 14 men) took part in the study. The three-dimensional scenery, presented by means of the Oculus system, oscillated in the sagittal plane with frequencies equal to 0.7 Hz and 1.4 Hz. The frequency value during the measurement was constant or changed in the middle of the test. Measurements were conducted on the FDM Zebris platform. The results were analyzed using developed coefficients determined on the basis of the Short-time Fourier transform (STFT). The use of frequency-domain analyses confirmed that in the COP movement, one can observe a cyclical component corresponding to following the scenery, as well as the appearance of other cyclical components whose observation is important in terms of assessing the ability to maintain balance. It has been shown that the changes in the average COP speed that occur during the measurement can result from changes related to the movement of following the scenery as well as additional body movements indicating a greater or lesser loss of balance. It has been shown that there are differences in the COP movement provoked by the movement of the surrounding scenery, which depend on the parameters of the introduced disturbances - something that can only be observed in results obtained in the frequency domain. The conducted research shows that in measurements involving the ability to maintain one's balance conducted in sensory conflict conditions, standard time-domain analyses should be supplemented with other types of data analysis, e.g. frequency domain analyses.

Personalized balance games for children with cerebral palsy: A pilot study

PURPOSE

To assess the changes in balance function in children with cerebral palsy (CP) after two weeks of daily training with personalized balance games.

METHODS

Twenty-five children with CP, aged 5 to 18 years were randomly selected for experimental or control groups. Over a period of two weeks, all participants received 8-9 game sessions for 15-20 minutes, totaling 150-160 minutes. The experimental group used personalized balance games available from the GAmification for Better LifE (GABLE) online serious gaming platform. Children from the control group played Nintendo Wii games using a handheld Wii Remote. Both groups received the same background treatment. Recorded outcome measures were from a Trunk Control Measurement Scale (TCMS), Timed Up & Go Test (TUG), Center of Pressure Path Length (COP-PL), and Dynamic Balance Test (DBT).

RESULTS

After two weeks of training in the experimental group TCMS scores increased by 4.5 points (SD = 3.5, p< 0.05) and DBT results increased by 0.88 points (IQR = 1.03, p< 0.05) while these scores did not change significantly in the control group. Overall, TUG and COP-PL scores were not affected in either group.

CONCLUSION

This study demonstrates improvement of balancing function in children with CP after a two-week course of training with personalized rehabilitation computer games.

Anterior-Posterior Balance Perturbation Protocol Using Lifelike Virtual Reality Environment

Virtual reality (VR) paradigms have proved to be a valid method to challenge and perturb balance. There is little consensus in the literature on the best protocol design to perturb balance and induce postural sway. Current VR interventions still lack a well-defined standardized metric to generate a virtual environment that can perturb balance in an efficacious, lifelike, and repeatable manner. The objective of this study was to investigate different configurations of amplitude and frequency in an anterior-posterior translation VR environment, that is, lifelike and scaled. Thirteen young adults with no conditions affecting balance were recruited. Balance was challenged by anterior-posterior sinusoidal movement of the lab image within the VR headset. Four different amplitudes of the sinusoidal movement were tested: 1, 5, 10, and 20 cm, with each amplitude being presented at 2 test frequencies : 0.5 and 0.25 Hz. Mean center of pressure velocity was significantly greater than baseline at 0.5 Hz and amplitudes of 10 and 20 cm. Mean center of pressure at approximate entropy was greater than baseline at 0.5 Hz and amplitude of 20 cm. The results suggest that sinusoidal movement of a realistic VR environment produces altered balance compared with baseline quiet standing, but only under specific movement parameters.

The Effectiveness of Virtual Reality Exercise on Individual's Physiological, Psychological and Rehabilitative Outcomes: A Systematic Review

Objective purpose: This review synthesized the literature examining the effects of virtual reality (VR)-based exercise on physiological, psychological, and rehabilitative outcomes in various populations. Design: A systematic review. Data sources: 246 articles were retrieved using key words, such as "VR", "exercise intervention", "physiological", "psychology", and "rehabilitation" through nine databases including Academic Search Premier and PubMed. Eligibility criteria for selecting studies: 15 articles which met the following criteria were included in the review: (1) peer-reviewed; (2) published in English; (3) randomized controlled trials (RCTs), controlled trials or causal-comparative design; (4) interventions using VR devices; and (5) examined effects on physiological, psychological, and/or rehabilitative outcomes. Descriptive and thematic analyses were used. Results: Of the 12 articles examining physiological outcomes, eight showed a positive effect on physical fitness, muscle strength, balance, and extremity function. Only four articles examined the effects on psychological outcomes, three showed positive effects such that VR exercise could ease fatigue, tension, and depression and induce calmness and enhance quality of life. Nine articles investigated the effects of VR-based exercise on rehabilitative outcomes with physiological and/or psychological outcomes, and six observed significant positive changes. In detail, patients who suffered from chronic stroke, hemodialysis, spinal-cord injury, cerebral palsy in early ages, and cognitive decline usually saw better improvements using VR-based exercise. Conclusion: The findings suggest that VR exercise has the potential to exert a positive impact on individual's physiological, psychological, and rehabilitative outcomes compared with traditional exercise. However, the quality, quantity, and sample size of existing studies are far from ideal. Therefore, more rigorous studies are needed to confirm the observed positive effects.

Application of Virtual Reality in Competitive Athletes - A Review

The purpose of this study was to determine the state of the art in the area of virtual reality in competitive athletes of different levels of expertise in various disciplines and point the areas of its application. Articles published before August 2018 were considered in our review. The PubMed, SCOPUS, SportDiscus and Medline databases were searched. A combination of the following search terms was used: virtual reality, virtual environment, virtual system, athletes, sports, physical training, sport performance, physical exercises. Studies involved healthy competitive athletes. A total of 18 articles met the inclusion criteria. There were three areas of application of virtual reality to sport: performance analysis, simulation improvement and virtual training. Competitive athletes were mostly examined in a semi-immersive setting. In conclusion, virtual reality seems to play a marginal role in competitive athletes' training. Due to the fact that virtual reality interventions bring significant improvements in clinical research, well-designed randomized control trials with detailed virtual training programmes are required in the future. Practically, virtual reality is effectively and commonly used to analyse performance in competitive athletes. There is still a need of creating fully interactive VR, where athletes will be able to cooperate with a virtual partner and influence the environment.

The Effect of Virtual Reality Games on the Gross Motor Skills of Children with Cerebral Palsy: A Meta-Analysis of Randomized Controlled Trials

This review aimed to systematically evaluate the rehabilitatitive effect of Virtual Reality Games (VRGs) for gross motor skills of children with cerebral palsy (CP), and to give scientific grounds for the formulation of rehabilitation therapy for these children. To this end, the literature in Chinese databases (CNKI and Wanfang Data) as well as the databases of other countries (Web of Science, PubMed, EBSCOhost, Informit, Scopus, Science Direct and ProQuest) from the establishment dates of these databases to June 3rd 2019 was retrieved in order to collect randomized controlled trials with regard to the intervention effect of VRGs and traditional therapy on gross motor skills of children with CP, and the literature was screened as per inclusion and exclusion criteria. The PEDro scale was then used to evaluate the methodological quality of the included literature, and the software Review Manager 5.3 was employed to analyze the combined effect size. As a result, 7 randomized controlled trials and 234 children with CP were included. Meta-analysis showed that VRGs could improve gross motor skills of children with CP. Combined effect size of gross motor skills SMD = 0.37 [95% CI = (0.06, 0.68), p = 0.02)]. In conclusion, the VRG intervention program can enhance gross motor skills of children with CP to some extent. In view of the limitations regarding methodologies and the quality and quantity of the literature in this research, more quality randomized controlled trials are needed so as to draw convincing conclusions of effect of VRG intervention on gross motor skill development of children with CP in future studies.