Virtual Reality Exercise Improves Mobility After Stroke

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONSUMER AND COMMUNITY CONSULTATION

Consumer and community were not involved in executing this study.

CONCLUSION

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

Fun and games: a scoping review of enjoyment and intensity assessment in studies of game-based interventions for gait rehabilitation in neurological disorders

PURPOSE

Exergames are used to promote gait rehabilitation in patients with neurological disorders because they are believed to heighten patient enjoyment and training intensity. This scoping review evaluated whether and how studies support these claims.

METHODS

A search for studies published up until October 2023 involving virtual reality or exergames for patients with neurological disorders (stroke, Parkinson's disease, multiple sclerosis, spinal cord injury) was conducted on PubMed and Scopus, with additional articles identified through backward and forward citation searching. Studies collecting gait measurements, with at least five participants and a control group were included. Data extracted were rationale, and whether participants' enjoyment of the intervention and training intensity were assessed.

RESULTS

1060 records were identified with 58 included in this review. There were 34 articles on stroke, 11 on multiple sclerosis, and 13 on Parkinson's disease. Participant enjoyment and greater training intensity were important rationales but were only evaluated in 12 and seven of the included studies, respectively.

CONCLUSION

Results highlight that participant enjoyment and heightened training intensity are commonly cited rationales for using exergames in gait rehabilitation, but these effects are assumed and not routinely measured or analysed. Greater consistency is needed in the design and execution of exergaming studies for neurological disorders.

The effect of balance training using touch controller-based fully immersive virtual reality devices on balance and walking ability in patients with stroke: A pilot randomized controlled trial

BACKGROUND

Fully immersive virtual reality (FIVR) removes information from the real world and replaces it with computer-generated data, creating the impression of being in a genuine virtual world.

OBJECTIVE

To evaluate the effects of balance training using touch controller-based FIVR devices on balance and walking abilities in patients with stroke.

METHODS

The participants were randomly categorized into the FIVR group (n = 18) and control group (n = 18). The control group received conventional therapy for 5 sessions, 30 minutes per week, for 5 weeks. The FIVR group practiced additional touch controller-based FIVR balance training for 3 sessions of 30 minutes per week for 5 weeks and changes in balance and walking ability were measured for both groups.

RESULTS

Touch controller-based FIVR balance training significantly improved the Berg Balance Scale (BBS) and, timed up-and-go (TUG) test results (P < .01). There was also significant improvement in gait abilities, including gait velocity, step length of the affected side, stride length, and single limb support of the affected side (P < .01).

CONCLUSION

Touch controller-based FIVR balance training improved balance and gait in patients with stroke. These results indicate that touch controller-based FIVR balance training is feasible and suitable for patients with stroke, providing a promising avenue for rehabilitation.

Advances in Neurorehabilitation: Strategies and Outcomes for Traumatic Brain Injury Recovery

Traumatic brain injury (TBI) consists of an external physical force that causes brain function impairment or pathology and globally affects 50 million people each year, with a cost of 400 billion US dollars. Clinical presentation of TBI can occur in many forms, and patients usually require prolonged hospital care and lifelong rehabilitation, which leads to an impact on the quality of life. For this narrative review, no particular method was used to extract data. With the aid of health descriptors and Medical Subject Heading (MeSH) terms, a search was thoroughly conducted in databases such as PubMed and Google Scholar. After the application of exclusion and inclusion criteria, a total of 146 articles were effectively used for this review. Results indicate that rehabilitation after TBI happens through neuroplasticity, which combines neural regeneration and functional reorganization. The role of technology, including artificial intelligence, virtual reality, robotics, computer interface, and neuromodulation, is to impact rehabilitation and life quality improvement significantly. Pharmacological intervention, however, did not result in any benefit when compared to standard care and still needs further research. It is possible to conclude that, given the high and diverse degree of disability associated with TBI, rehabilitation interventions should be precocious and tailored according to the individual's needs in order to achieve the best possible results. An interdisciplinary patient-centered care health team and well-oriented family members should be involved in every stage. Lastly, strategies must be adequate, well-planned, and communicated to patients and caregivers to attain higher functional outcomes.

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

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

Perceptions of stroke survivors regarding factors affecting adoption of technology and exergames for rehabilitation

BACKGROUND

Task-specific motor training and repetitive practice are essential components of clinical rehabilitation. Emerging evidence suggests that incorporating gaming interfaces (also referred to as "exergames"), including virtual reality and augmented reality (VR/AR)-based interfaces for motor training, can enhance the engagement and efficacy of poststroke rehabilitation.

OBJECTIVE

To investigate perceptions of individuals with stroke regarding technology and exergames for rehabilitation.

DESIGN

This qualitative phenomenological study included a convenience sample of 11 individuals with stroke (61.7 ± 12.4 years, 6 women and 5 men, 63.5 ± 41.2 months post stroke).

SETTING

Community.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Semistructured open-ended focus-group interviews to understand their perceptions on technology and exergames to improve recovery were coded using thematic content analysis.

RESULTS

Individuals with stroke were comfortable using smartphones, computers, and rehabilitation technologies but had limited experiences using exergames and VR/AR devices. Individuals with stroke were motivated to use technologies and exergames to improve their functional recovery. Participants identified facilitators (eg, enhancing functional recovery, feedback, therapist supervision) and barriers (eg, safety, inaccessibility, inadequate knowledge) to adopting exergames in their daily lives. Participants wanted the exergames to be customizable, goal oriented, and enjoyable to maintain their engagement. They were willing to use exergames to improve their functional recovery but indicated that these games could not replace the therapist's supervision.

CONCLUSIONS

Despite having limited experiences with exergames, people post stroke perceived that exergames could promote functional recovery. The perspectives gained from the present study can inform user-centered game design for neurorehabilitation.

Challenges With the Use of Digital Sham: Systematic Review and Recommendations

BACKGROUND

Digital therapeutics (DTx) are software-based products that prevent, manage, or treat a medical condition and are delivered through a smartphone app, web application, or wearable device. Clinical trials assessing DTx pose challenges, foremost among which is designing appropriate digital shams (or digital placebos), which should ideally mimic DTx (in terms of design, components, and duration of treatment) while omitting the active principle or component.

OBJECTIVE

The objective of our review was to understand how digital shams are being used in clinical research on DTx in neuroscience, which is the most common therapy area for DTx.

METHODS

We conducted a systematic literature review of DTx in neuroscience (including neurodevelopmental, neurodegenerative, and psychiatric disorders) with a focus on controlled clinical trials involving digital shams. Studies were identified from trial registries (ClinicalTrials.gov, the European Union Clinical Trials Register, and Trial Trove) and through structured searches in MEDLINE and Embase (both via the Embase website) and were limited to articles in English published from 2010 onward. These were supplemented by keyword-based searches in PubMed, Google, and Google Scholar and bibliographic searches. Studies assessing DTx in neuroscience (including neurodevelopmental, neurodegenerative, and psychiatric disorders) were included. Details related to the publication, DTx, comparator, patient population, and outcomes were extracted and analyzed.

RESULTS

Our search criteria identified 461 neuroscience studies involving 213 unique DTx. Most DTx were extended reality based (86/213, 40.4%) or mobile device based (56/213, 26.3%); 313 were comparative, of which 68 (21.7%) used shams. The most common therapeutic areas assessed in these studies were stroke (42/213, 19.7%), depression (32/213, 15%), and anxiety (24/213, 11.3%). The most common treatments were cognitive behavioral therapy or behavioral therapy (67/213, 32.4%), physical rehabilitation (60/213, 28.2%), and cognitive training (41/213, 19.2%). We identified the following important issues related to the use of digital shams in neuroscience: shams were not validated before use in studies, they varied widely in design (from being nearly identical to the DTx to using different software programs altogether), and the level of patient engagement or satisfaction with the sham and the impact of the sham on study outcomes were infrequently reported.

CONCLUSIONS

Digital shams are critical for the clinical development of DTx in neuroscience. Given the importance of sham controls in evaluating DTx efficacy, we provide recommendations on the key information that should be reported in a well-designed DTx trial and propose an algorithm to allow the correct interpretation of DTx study results. Sham-controlled studies should be routinely used in DTx trials-in early-phase studies-to help identify DTx active components and-in late-phase studies-to confirm the efficacy of DTx. The use of shams early in development will ensure that the appropriate sham control is used in later confirmatory trials.

Effect of Physiotherapy Treatment with Immersive Virtual Reality in Subjects with Stroke: A Protocol for a Randomized Controlled Trial

BACKGROUND

Many stroke survivors suffer from sensorimotor deficits, especially balance impairments. The purpose of this trial is to investigate whether the designed Immersive Virtual Reality training program is better in the short term (15 sessions) and in the medium term (30 sessions) than physiotherapy training with Bayouk, Boucher and Leroux exercises, with respect to static balance in sitting and standing, dynamic balance and quality of life in patients with balance impairment in stroke survivors.

METHODS

This study is a randomized controlled trial with two treatment arms and evaluators blinded, and a functionality treatment group in combination with specific balance exercise training according to Bayouk, Boucher and Leroux (control group) or a balanced treatment using Immersive VR. The primary outcome will be static, Dynamic balance and gait measured by Bestest Assessment Score (BESTest), Berg Scale (BBS), Pass Scale (PASS) and Time Up and Go test (TUG). The secondary outcome will be the stroke-associated quality of life using the Stroke Quality of Life Scale (ECVI-38).

CONCLUSIONS

The results of this study may add new insights into how to address balance using Immersive Virtual Reality after a stroke. If the new training approach proves effective, the results may provide insight into how to design more comprehensive protocols in the future for people with balance impairments after stroke.

Breathlessness in a virtual world: An experimental paradigm testing how discrepancy between VR visual gradients and pedal resistance during stationary cycling affects breathlessness perception

INTRODUCTION

The sensation of breathlessness is often attributed to perturbations in cardio-pulmonary physiology, leading to changes in afferent signals. New evidence suggests that these signals are interpreted in the light of prior "expectations". A misalignment between afferent signals and expectations may underly unexplained breathlessness. Using a novel immersive virtual reality (VR) exercise paradigm, we investigated whether manipulating an individual's expectation of effort (determined by a virtual hill gradient) may alter their perception of breathlessness, independent from actual effort (the physical effort of cycling).

METHODS

Nineteen healthy volunteers completed a single experimental session where they exercised on a cycle ergometer while wearing a VR headset. We created an immersive virtual cycle ride where participants climbed up 100 m hills with virtual gradients of 4%, 6%, 8%, 10% and 12%. Each virtual hill gradient was completed twice: once with a 4% cycling ergometer resistance and once with a 6% resistance, allowing us to dissociate expected effort (virtual hill gradient) from actual effort (power). At the end of each hill, participants reported their perceived breathlessness. Linear mixed effects models were used to examine the independent contribution of actual effort and expected effort to ratings of breathlessness (0-10 scale).

RESULTS

Expectation of effort (effect estimate ± std. error, 0.63 ± 0.11, P < 0.001) and actual effort (0.81 ± 0.21, P < 0.001) independently explained subjective ratings of breathlessness, with comparable contributions of 19% and 18%, respectively. Additionally, we found that effort expectation accounted for 6% of participants' power and was a significant, independent predictor (0.09 ± 0.03; P = 0.001).

CONCLUSIONS

An individuals' expectation of effort is equally important for forming perceptions of breathlessness as the actual effort required to cycle. A new VR paradigm enables this to be experimentally studied and could be used to re-align breathlessness and enhance training programmes.

Comparative efficacy of gait training for balance outcomes in patients with stroke: A systematic review and network meta-analysis

Background

Growing evidence suggests that gait training can improve stroke patients’ balance outcomes. However, it remains unclear which type of gait training is more effective in improving certain types of balance outcomes in patients with stroke. Thus, this network meta-analysis (NMA) included six types of gait training (treadmill, body-weight-supported treadmill, virtual reality gait training, robotic-assisted gait training, overground walking training, and conventional gait training) and four types of balance outcomes (static steady-state balance, dynamic steady-state balance, proactive balance, and balance test batteries), aiming to compare the efficacy of different gait training on specific types of balance outcomes in stroke patients and determine the most effective gait training.

Method

We searched PubMed, Embase, Medline, Web of Science, and Cochrane Library databases from inception until 25 April 2022. Randomized controlled trials (RCTs) of gait training for the treatment of balance outcomes after stroke were included. RoB2 was used to assess the risk of bias in the included studies. Frequentist random-effects network meta-analysis (NMA) was used to evaluate the effect of gait training on four categories of balance outcomes.

Result

A total of 61 RCTs from 2,551 citations, encompassing 2,328 stroke patients, were included in this study. Pooled results showed that body-weight-support treadmill (SMD = 0.30, 95% CI [0.01, 0.58]) and treadmill (SMD = 0.25, 95% CI [0.00, 0.49]) could improve the dynamic steady-state balance. Virtual reality gait training (SMD = 0.41, 95% CI [0.10, 0.71]) and body-weight-supported treadmill (SMD = 0.41, 95% CI [0.02, 0.80]) demonstrated better effects in improving balance test batteries. However, none of included gait training showed a significant effect on static steady-state balance and proactive balance.

Conclusion

Gait training is an effective treatment for improving stroke patients’ dynamic steady-state balance and balance test batteries. However, gait training had no significant effect on static steady-state balance and proactive balance. To achieve maximum efficacy, clinicians should consider this evidence when recommending rehabilitation training to stroke patients. Considering body-weight-supported treadmill is not common for chronic stroke patients in clinical practice, the treadmill is recommended for those who want to improve dynamic steady-state balance, and virtual reality gait training is recommended for those who want to improve balance test batteries.

Limitation

Missing evidence in relation to some types of gait training is supposed to be taken into consideration. Moreover, we fail to assess reactive balance in this NMA since few included trials reported this outcome.

Systematic Review Registration

PROSPERO, identifier CRD42022349965.

Use of Virtual Reality and Videogames in the Physiotherapy Treatment of Stroke Patients: A Pilot Randomized Controlled Trial

A stroke is a neurological condition with a high impact in terms of physical disability in the adult population, requiring specific and effective rehabilitative approaches. Virtual reality (VR), a technological approach in constant evolution, has great applicability in many fields of rehabilitation, including strokes. The aim of this study was to analyze the effects of a traditional neurological physiotherapy-based approach combined with the implementation of a specific VR-based program in the treatment of patients following rehabilitation after a stroke. Participants (n = 24) diagnosed with a stroke in the last six months were randomly allocated into a control group (n = 12) and an experimental group (n = 12). Both groups received one-hour sessions of neurological physiotherapy over 6 weeks, whilst the experimental group was, in addition, supplemented with VR. Patients were assessed through the Daniels and Worthingham Scale, Modified Ashworth Scale, Motor Index, Trunk Control Test, Tinetti Balance Scale, Berg Balance Scale and the Functional Ambulation Classification of the Hospital of Sagunto. Statistically significant improvements were obtained in the experimental group with respect to the control group on the Motricity Index (p = 0.005), Trunk Control Test (p = 0.008), Tinetti Balance Scale (p = 0.004), Berg Balance Scale (p = 0.007) and the Functional Ambulation Classification of the Hospital of Sagunto (p = 0.038). The use of VR in addition to the traditional physiotherapy approach is a useful strategy in the treatment of strokes.

Virtual reality in post-stroke neurorehabilitation - a systematic review and meta-analysis

BACKGROUND

Stroke is a neurological disorder and one of the leading causes of disability worldwide. The patient may lose the ability to adequately move the extremities, perceive sensations, or ambulate independently. Recent experimental studies have reported the beneficial influence of virtual reality training strategies on improving overall functional abilities for stroke survivors.

METHODS

Conducted a systematic review of the literature using the following keywords to retrieve the data: stroke, virtual reality, motor deficits, neurorehabilitation, cognitive impairments, and sensory deficits. A random-effect meta-analysis was performed for seven scales - one cognitive (MMSE) and six motor (Fugl-Meyer, Berg Balance Scale, Time up and go, Wolf motor function, 10 m walk, Brunnstrom score).

OBJECTIVE

To organize and compare all the available data regarding the effectiveness of virtual reality for stroke rehabilitation.

RESULTS

This literature reviewed 150 studies and included 46 for qualitative and 27 for quantitative analysis. There was no statistically significant difference between groups in MMSE score (MD = 0.24, 95%CI = ((-0.42) -(0.9)), p = .47, I² = 0%) and Fugl-Meyer score (MD = (-0.38), 95%CI = ((-12.88)-(12.11)), p = .95, I² = 98%) . The statistical significance was not reached in any of the other outcomes.

CONCLUSIONS

This review supports that stroke rehabilitation programs incorporating virtual reality are associated with improved functional outcomes, but there is no statistically significant difference compared to standard therapy.

Acute Effects of Virtual Reality Exercise Biking on College Students' Physical Responses

Purpose: Current evidence regarding the use of commercially available immersive virtual reality (VR) headsets and compatible VR exercise apparatus in the promotion of individuals' physical activity (PA) is lacking. This exploratory study investigated the acute effects of a VirZoom VR exercise bike (vBike) on college students' physical responses compared to an exergaming bike (eBike) and a traditional stationary exercise bike (tBike). Method: Forty-eight college students (34 females, X_age = 23.58 ± 3.39; X_BMI = 23.81 ± 3.57) completed three separate 20-minute cycling sessions on the vBike, eBike, and tBike in a counterbalanced order. Outcomes included rating of perceived exertion (RPE), assessed at 4-minute intervals throughout each cycling session, and overall PA, operationalized as pedal revolution counts (PRC) during each session. Results: Linear models indicated significant group differences between exercise modalities for RPE (F (2,138) = 14.76-27.30, all p < .001, η² = 0.17-0.27) and PRC (F (2,138) = 74.862, p < .001, η² = 0.48). Pairwise comparisons revealed that RPE was reported significantly higher at each time point (i.e., 4th minute, 8th minute, 12th minute, 16th minute, and 20th minute) during the tBike session vs. the vBike and eBike sessions (p < .001) and that participants had higher PRC during the vBike session vs. the eBike and tBike sessions (p < .001). Conclusion: A commercially available VR exercise bike would trigger greater overall PA as compared to exergaming and traditional cycling while being perceived less intense. Future intervention studies conducted in real-world settings to determine cause and effect relationship are warranted.

Two Immersive Virtual Reality Tasks for the Assessment of Spatial Orientation in Older Adults with and Without Cognitive Impairment: Concurrent Validity, Group Comparison, and Accuracy Results

OBJECTIVE

Spatial disorientation is common in Alzheimer's disease (AD), Mild Cognitive Impairment (MCI), and preclinical individuals with AD biomarkers. However, traditional neuropsychological tests lack ecological validity for the assessment of spatial orientation and to date, there is still no gold standard. The current study aimed to determine the validity and accuracy of two virtual reality tasks for the assessment of spatial orientation.

METHODS

We adapted two spatial orientation tasks to immersive virtual environments: a "survey to route" task in which participants had to transfer information from a map to their body position within a maze [Spatial Orientation in Immersive Virtual Environment Test (SOIVET) Maze], and an allocentric-type, route learning task, with well-established topographic landmarks (SOIVET Route). A total of 19 MCI patients and 29 cognitively healthy older adults aged 61-92 participated in this study. Regular neuropsychological assessments were used for correlation analysis and participant performances were compared between groups. Receiver Operating Characteristic (ROC) curve analysis was performed for accuracy.

RESULTS

The SOIVET Maze correlated with measures of visuoperception, mental rotation, and planning, and was not related to age, educational level, or technology use profile. The SOIVET Route immediate correlated with measures of mental rotation, memory, and visuoconstruction, and was influenced only by education. Both tasks significantly differentiated MCI and control groups, and demonstrated moderate accuracy for the MCI diagnosis.

CONCLUSION

Traditional neuropsychological assessment presents limitations and immersive environments allow for the reproduction of complex cognitive processes. The two immersive virtual reality tasks are valid tools for the assessment of spatial orientation and should be considered for cognitive assessments of older adults.

Is Virtual Reality Training More Effective Than Traditional Physical Training on Balance and Functional Mobility in Healthy Older Adults? A Systematic Review and Meta-Analysis

Objective

The studies showed the benefits of virtual reality training (VRT) for functional mobility and balance in older adults. However, a large variance in the study design and results is presented. We, thus, completed a systematic review and meta-analysis to quantitatively examine the effects of VRT on functional mobility and balance in healthy older adults.

Methods

We systematically reviewed the publications in five databases. Studies that examine the effects of VRT on the measures of functional mobility and balance in healthy older adults were screened and included if eligible. Subgroup analyses were completed to explore the effects of different metrics of the intervention design (e.g., session time) on those outcomes related to functional mobility and balance.

Results

Fifteen studies of 704 participants were included. The quality of these studies was good. Compared to traditional physical therapy (TPT), VRT induced greater improvement in TUG (MD = -0.31 s, 95% CI = -0.57 to -0.05, p = 0.02, I 2 = 6.34%) and one-leg stance with open eyes (OLS-O) (MD = 7.28 s, 95% CI = 4.36 to 10.20, p = 0.00, I 2 = 36.22%). Subgroup analyses revealed that immersive VRT with more than 800 min of total intervention time over 8 weeks and at least 120 min per week and/or designed by the two motor-learning principles was optimal for functional mobility and balance.

Conclusion

Virtual reality training can significantly improve functional mobility and balance in healthy older adults compared to TPT, and the findings provided critical knowledge of the optimized design of VRT that can inform future studies with more rigorous designs.

Systematic Review Registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021297085].

Backward Walking Training Impacts Positive Effect on Improving Walking Capacity after Stroke: A Meta-Analysis

Objective: The meta-analysis aimed to investigate the potential effect of backward walking training (BWT) on walking function improvement among stroke patients. Data sources: Eligible studies were systematically searched in PubMed, Embase, Web of Science, and Cochrane Library. Methods: Heterogeneity among enrolled studies was assessed. Weighted mean difference (WMD) with its 95% confidence interval (CI) was used to pool the outcomes. Results: Seven articles were included. BWT significantly improved motor functions of stroke patients including 10-meter walk test (WMD (95% CI) = 0.11 (0.01, 0.21) meters/second; p = 0.03); cadence (WMD (95% CI) = 4.00 (0.99, 7.02) step/minute; p < 0.01); Berg balance scale (WMD (95% CI) = 4.38 (2.60, 6.15); p < 0.01); paretic step length (WMD (95% CI) = 5.32 (1.97, 8.67) cm; p < 0.01); and stride length (WMD (95% CI) = 6.61 (0.70, 12.51) cm; p = 0.03) as compared with control group. Conclusion: Our study revealed that BWT had a positive influence on walking function improvement among patients after stroke.

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.

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

Objective

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

Materials and Methods

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

Results

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

Conclusions

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

Effects of Immersive and Non-Immersive Virtual Reality on the Static and Dynamic Balance of Stroke Patients: A Systematic Review and Meta-Analysis

(1) Background: The development of new technologies means that the use of virtual reality is increasingly being implemented in rehabilitative approaches for adult stroke patients.

OBJECTIVE

To analyze the existing scientific evidence regarding the application of immersive and non-immersive virtual reality in patients following cerebrovascular incidents and their efficacy in achieving dynamic and static balance. (2) Data sources: An electronic search of the databases Medline, Cochrane Library, PEDro, Scopus, and Scielo from January 2010 to December 2020 was carried out using the terms physiotherapy, physical therapy, virtual reality, immersive virtual reality, non-immersive virtual reality, stroke, balance, static balance, and dynamic balance.

SELECTION OF STUDIES

Randomized controlled trials in patients older than 18 developed with an adult population (>18 years old) with balance disorders as a consequence of suffering a stroke in the previous six months before therapeutic intervention, including exercises harnessing virtual reality in their interventions and evaluations of balance and published in English or Spanish, were included. A total of two hundred twenty-seven articles were found, ten of which were included for review and of these, nine were included in the subsequent meta-analysis. (3) Data extraction: Two authors selected the studies and extracted their characteristics (participants, interventions, and validation instruments) and results. The methodological quality of the studies was evaluated using the PEDro scale, and the risk of bias was determined using the Cochrane risk-of-bias tool.

DATA SYNTHESIS

Of the selected studies, three did not show significant improvements and seven showed significant improvements in the intervention groups in relation to the variables. (4) Conclusions: Non-immersive virtual reality combined with conventional rehabilitation could be considered as a therapeutic option.

Digital therapeutics in neurology

Digital therapeutics (DTx) is a section of digital health defined by the DTx Alliance as “delivering evidence-based therapeutic interventions to patients that are driven by software to prevent, manage, or treat a medical disorder or disease. They are used independently or in concert with medications, devices, or other therapies to optimize patient care and health outcomes”. Chronic disabling diseases could greatly benefit from DTx. In this narrative review, we provide an overview of DTx in the care of patients with neurological dysfunctions.

Effects of Visual Flow Alterations on Psychophysiological Responses to Virtual Reality Exercise

Virtual reality (VR) technology combined with exercise, called VR exercise, is believed to have beneficial effects on mood; but VR factors contributing to improved mood remain ambiguous. The purpose of this study was to examine the effect of visual flow speed on psychophysiological responses (i.e., physiological responses, ratings of perceived exertion or RPE, and mood) to immersive VR exercise in a simulated natural environment. Eighteen male participants (Mage =23.1, SD = 1.9 years) cycled an ergometer at 80 watts for 5 minutes on three separate occasions while watching a first-person VR movie through VR goggles at three different speeds of visual flow, corresponding to 7.5 km.h^-1, 15 km.h^-1, and 22.5 km.h^-1. The order of the three speeds was randomized in a counterbalanced design. We measured heart rate, oxygen uptake, minute ventilation, respiratory rate, and cadence during the exercise, and we recorded ratings of perceived exertion (RPE) and mood immediately after the exercise. We evaluated mood states with the Two-Dimensional Mood Scale. One-way repeated measures analysis of variance or the Friedman test revealed no significant effects on any physiological variables, RPE or cadence as a result of altered visual flow speed during VR exercise (p > .05). However, speed of visual flow significantly influenced participant ratings of Vitality (p = 0.01) and Pleasure (p = 0.02), with the faster speed resulting in a more positive mood state. As these findings showed that VR exercise with faster visual flow induced positive mood states, we recommend faster visual flow to induce better mood states in VR exercise.

What can virtual reality offer to stroke patients? A narrative review of the literature

BACKGROUND

Studies demonstrated the efficacy of virtual reality (VR) as a method supporting the post-stroke neuro-rehabilitation process by activating motor learning processes. Nevertheless, stroke is frequently accompanied by serious psychological problems including depression, which is associated with an increased risk of mortality, lower post-stroke physical activity, and higher disability in stroke patients.

OBJECTIVES

To explore the current use of VR as a method supporting the neuro-rehabilitation process, both in physical and psychological dimensions.

METHODS

An exploratory review was conducted with a narrative synthesis. PubMed was used for literature search. Search includes the use of VR in physical rehabilitation, and as support therapy in psychiatric disorders. Both primary research and systematic reviews were included.

RESULTS

In neurological disorders rehabilitation, out of 22 studies, 16 concerned stroke survivors. In psychiatric disorders, 44 literature reviews were included.

CONCLUSION

The studies confirmed the effectiveness of various forms of VR treatment in the alleviation of psychological and behavioral problems and psychiatric disorders. There is a shortage of VR-based technological solutions that would, besides physical rehabilitation, offer stroke patients therapeutic tools to alleviate psychological disturbance and improve the patient's mood and motivation. Such solutions will most likely become a field of intensive research in the coming years.

The effects of exergaming on pain, postural control, technology acceptance and flow experience in older people with chronic musculoskeletal pain: a randomised controlled trial

BACKGROUND

Older people with chronic musculoskeletal pain are at risk of falls. This study aimed to investigate the effects of exergaming on pain and postural control in older people with chronic musculoskeletal pain. Secondary outcomes were technology acceptance, flow experience, perceived physical exertion, expended mental effort and heart rate.

METHODS

Fifty four older adults (age: 71 ± 5 years) with chronic musculoskeletal pain were randomised into 2 groups. Group 1 received exergaming training using the Interactive Rehabilitation and Exercise System (IREX®). Group 2 undertook traditional gym-based exercise (TGB). Both groups completed twice weekly 40-min exercise sessions for 6 weeks. Perceived pain was measured using a numeric pain rating scale and the Multidimensional Affect and Pain Survey questionnaire. Postural control was measured as sway using a Kistler™ force platform. Technology acceptance was measured with the Unified Theory of Acceptance and Use of Technology questionnaire and flow experience with the Flow State Scale. Physiological measures of perceived physical exertion, expended mental effort and heart rate were recorded during all sessions.

RESULTS

The exergaming group demonstrated significant reductions in pain intensity and thermal pain including a near significant approach in physical engagement in comparison to TGB group. Although no intervention effects on postural control were found, the exergaming group showed significant improvements in three sway measures (AP SD, ML SD and AP range) over time whereas significant improvements in ML range were found in the TGB group. Relating to technology acceptance, significant intervention effects on social influence and behavioural intention were found in the TGB group instead, although both groups demonstrated increases of acceptance over time. Regarding flow experience, concentration at task was significantly influenced in the TGB group and significant increases in flow variables over time were observed in both groups. Significant increases over time in perceived physical exertion and expended mental effort were found in both groups.

CONCLUSION

Our findings support the potential of exergaming to alleviate pain and improve balance in older people with chronic musculoskeletal pain. Both forms of exercise are acceptable, intrinsically motivating and show evidence of benefit to older people with chronic musculoskeletal pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04029285 (retrospectively registered, July 23, 2019).

How Commercially Available Virtual Reality-Based Interventions Are Delivered and Reported in Gait, Posture, and Balance Rehabilitation: A Systematic Review

OBJECTIVE

Virtual reality (VR) technologies are increasingly used in physical rehabilitation; however, it is unclear how VR interventions are being delivered, and, in particular, the role of the therapist remains unknown. The purpose of this study was to systematically evaluate how commercially available VR technologies are being implemented in gait, posture, and balance rehabilitation, including justification, content, procedures, and dosage of the intervention and details of the therapist role.

METHODS

Five databases were searched between 2008 and 2018. Supervised interventional trials with >10 adult participants using commercially available VR technologies to address mobility limitations were independently selected by 2 authors. One author extracted reported intervention characteristics into a predesigned table and assessed methodological quality, which was independently verified by a second author. A total of 29 studies were included.

RESULTS

Generally, minimal clinical reasoning was provided to justify technology or activity selection, with recreational systems and games used most commonly (n = 25). All but 1 study used a single interventional technology. When explicitly described, the intervention was delivered by a physical therapist (n = 14), a therapist assistant (n = 2), both (n = 1), or an occupational therapist (n = 1). Most studies reported supervision (n = 12) and safeguarding (n = 8) as key therapist roles, with detail of therapist feedback less frequently reported (n = 4). Therapist involvement in program selection, tailoring, and progression was poorly described.

CONCLUSION

Intervention protocols of VR rehabilitation studies are incompletely described and generally lack detail on clinical rationale for technology and activity selection and on the therapist role in intervention design and delivery, hindering replication and translation of research into clinical practice. Future studies utilizing commercially available VR technologies should report all aspects of intervention design and delivery and consider protocols that allow therapists to exercise clinical autonomy in intervention delivery.

IMPACT STATEMENT

The findings of this systematic review have highlighted that VR rehabilitation interventions targeting gait, posture, and balance are primarily delivered by physical therapists, whose most reported role was supervision and safeguarding. There was an absence of detail regarding complex clinical skills, such as tailoring of the intervention and reasoning for the choice of technology and activity. This uncertainty around the role of the therapist as an active ingredient in VR-based rehabilitation hinders the development of implementation guidelines. To inform the optimal involvement of therapists in VR rehabilitation, it is essential that future studies report on all aspects of VR intervention design and delivery.

Virtual reality training enhances gait poststroke: a systematic review and meta-analysis

Virtual reality (VR)-based interventions are gaining widespread attention for managing neurological disorders such as stroke. A metastatistical consensus regarding the intervention is strongly warranted. In this study, we attempt to address this gap in the literature and provide the current state of evidence for the effects of VR on gait performance. We conducted both between- and within-group meta-analyses to provide a state of evidence for VR. Moreover, we conducted a search adhering to PRISMA guidelines on nine databases. Out of 1866 records, 32 studies involving a total of 809 individuals were included in this review. Considering all included studies, significant enhancements in gait parameters were observed with VR-based interventions compared with conventional therapy. A between-group meta-analysis reported beneficial significant medium effects of VR training on cadence (Hedge's g = 0.55), stride length ((STrL; Hedge's g = 0.46), and gait speed (Hedge's g = 0.30). Similarly, a within-group meta-analysis further revealed positive medium effects of VR on cadence (Hedge's g = 0.76), STrL (Hedge's g = 0.61), and gait speed (Hedge's g = 0.69). Additional subgroup analyses revealed beneficial effects of joint application of VR and robot-assisted gait training on gait speed (Hedge's g = 0.50). Collectively, findings from this review provide evidence for the effectiveness of VR-based gait training for stroke survivors.

Effects of core stability exercise combined with virtual reality in collegiate athletes with nonspecific low back pain: a randomized clinical trial

Background

Nonspecific low back pain (LBP) in collegiate athletes is shown to be accompanied by poor core endurance. Consequently, trunk muscle stabilization exercises for lumbar instability are widely used. Virtual reality (VR) training can activate the cerebral cortex and enhance the cortex to control balance and improve motion function. The purpose of the study was to assess the effect of combined core stability exercises (CSE) and VR training in improving body balance and function in collegiate male athletes with nonspecific low back pain (LBP).

Results

The post-values of the experimental group were significantly higher than that of the control group for the dynamic balance in anterior (p = 0.031), posterolateral (p = 0.034), and posteromedial (p = 0.037) directions. Moreover, there was a significant difference in the post-values of both groups regarding reducing the Micheli Functional Scale in favor of the experimental group (p = 0.012).

Conclusions

CSE training plus virtual reality is more effective than CSE training alone in improving total body balance and dysfunction level in collegiate male athletes with nonspecific LBP. It is recommended that clinicians consider CSE combined with VR to maximize the improvement in overall body balance when developing rehabilitation programs for collegiate athletes with nonspecific low back pain.

Trial registration

Pan African Clinical Trial Registry, PACTR201907749053096. Retrospectively registered on 15 April 2019. https://pactr.samrc.ac.za/Researcher/ManageTrials.aspx

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Assessor-blinded, placebo-controlled randomized controlled trial.

SETTING

Stroke inpatient rehabilitation unit.

PARTICIPANTS

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

INTERVENTIONS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Effects of Video-Game Based Therapy on Balance, Postural Control, Functionality, and Quality of Life of Patients with Subacute Stroke: A Randomized Controlled Trial

Purpose

To determine the effects of a structured protocol using commercial video games on balance, postural control, functionality, quality of life, and level of motivation in patients with subacute stroke.

Methods

A randomized controlled trial was conducted. A control group (n = 25) received eight weeks of conventional rehabilitation consisting of five weekly sessions based on an approach for task-oriented motor training. The experimental group (n = 25) received eight weeks of conventional rehabilitation consisting of five weekly sessions based on an approach for task-oriented motor training. The experimental group (

Results

In the between-group comparison, statistically significant differences were observed in the Modified Rankin scores (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (

Conclusion

A protocol of semi-immersive video-game based therapy, combined with conventional therapy, may be effective for improving balance, functionality, quality of life, and motivation in patients with subacute stroke. This trial is registered with NCT03528395.

Acute Hemodynamic Effects of Virtual Reality-Based Therapy in Patients of Cardiovascular Rehabilitation: A Cluster Randomized Crossover Trial

OBJECTIVE

To analyze the acute hemodynamic effects of adding virtual reality-based therapy (VRBT) using exergames for patients undergoing cardiac rehabilitation (CR).

DESIGN

Crossover trial.

SETTING

Outpatient rehabilitation center.

PARTICIPANTS

Patients (N=27) with a diagnosis of cardiovascular disease or cardiovascular risk factors. Mean age (years) ± SD was 63.4±12.7 and mean body mass index (kg/m2) ± SD was 29.0±4.0.

INTERVENTIONS

Patients performed 1 VRBT session and 1 CR session on 2 nonconsecutive days. Each session comprised an initial rest, warm-up, conditioning, and recovery. During warm-up, in the VRBT session, games were performed with sensors to reproduce the movements of avatars and, in the CR session, patients were required to reproduce the movements of the physiotherapists. In the conditioning phase for VRBT, games were also played with motion sensors, dumbbells, and shin guards. The CR session consisted of exercises performed on a treadmill. The intensity of training was prescribed by heart rate reserve (HRR; 40%-70%).

MAIN OUTCOME MEASURES

The primary outcomes were heart rate, blood pressure, respiratory rate (RR), rating of perceived exertion (RPE), and peripheral oxygen saturation, evaluated before, during, and after the VRBT or CR session on 2 nonconsecutive days. The secondary outcome was to evaluate whether the patients achieved the prescribed HRR and the percentage of time they maintained this level during the VRBT session.

RESULTS

VRBT produces a physiological similar pattern of acute hemodynamic effects in CR. However, there was greater magnitude of heart rate, RR, and RPE (P<.01) during the execution of VRBT and until 5 minutes of recovery, observed at the moments of rest, and 1, 3, and 5 minutes of recovery.

CONCLUSIONS

Although the VRBT session produces similar physiological acute hemodynamic effects in CR, greater magnitudes of heart rate, RR, and RPE were observed during its execution and up to 5 minutes after the session.

Kinect Adventures versus physical exercise on depressive symptoms of older adults: A pilot study

Abstract Introduction: Depressive and anxiety disorders are considered the main cause of emotional suffering and decrease of quality of life among older adults. It has been suggested that the practice of physical exercise can be a treatment option for anxiety and depression. Alternative approaches such serious games show promise for reducing depression symptoms. Objective: To compare the effect of virtual reality, in the form of commercially available interactive Kinect Adventures video games, compared to a standard physical exercise program on depressive symptoms of older adults. Method: This is a pilot study, parallel group, single-blind randomized controlled pilot trial that recruited two intervention groups: Interactive Video Game Kinect Adventures (IVG, n=8) versus usual physical exercise program (PEP, n=6). The two groups completed a seven week program with a total of fourteen 60-minute sessions divided into two sessions a week. The IVG completed individual training sessions using the Microsoft Xbox Kinect Adventures games and the PEP performed a group exercise program. Depression symptoms were measured using the Geriatric Depression Scale (GDS-15). This measure was assessed pre-intervention, post intervention and at 30-day follow-up. Results: There was a significant effect of assessment without group effect or interaction between factors, in the GDS-15 (RM-ANOVA, P < 0.0001). Both groups showed improvement in the GDS-15 post intervention assessment that was maintained after 30-day follow-up (Bonferroni post hoc test, P < 0.05). Conclusion: The results of this study suggest that both Interactive Kinect Adventures video games and physical exercise provide beneficial effects on depressive symptoms of older adults.

Altered visual feedback from an embodied avatar unconsciously influences movement amplitude and muscle activity

Evidence suggests that the sense of the position of our body parts can be surreptitiously deceived, for instance through illusory visual inputs. However, whether altered visual feedback during limb movement can induce substantial unconscious motor and muscular adjustments is not known. To address this question, we covertly manipulated virtual body movements in immersive virtual reality. Participants were instructed to flex their elbow to 90° while tensing an elastic band, as their virtual arm reproduced the same, a reduced (75°), or an amplified (105°) movement. We recorded muscle activity using electromyography, and assessed body ownership, agency and proprioception of the arm. Our results not only show that participants compensated for the avatar’s manipulated arm movement while being completely unaware of it, but also that it is possible to induce unconscious motor adaptations requiring significant changes in muscular activity. Altered visual feedback through body ownership illusions can influence motor performance in a process that bypasses awareness.

Digital Therapeutics: Emerging New Therapy for Neurologic Deficits after Stroke

Digital therapeutics is an evidence-based intervention using high-quality software, with the sole purpose of treatment. As many healthcare systems are encountering high demands of quality outcomes, the need for digital therapeutics is gradually increasing in the clinical field. We conducted review of the implications of digital therapeutics in the treatment of neurological deficits for stroke patients. The implications of digital therapeutics have been discussed in four domains: cognition, speech and aphasia, motor, and vision. It was evident that different forms of digital therapeutics such as online platforms, virtual reality trainings, and iPad applications have been investigated in many trials to test its feasibility in clinical use. Although digital therapeutics may deliver high-quality solutions to healthcare services, the medicalization of digital therapeutics is accompanied with many limitations. Clinically validated digital therapeutics should be developed to prove its efficacy in stroke rehabilitation.

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

Background

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

Methods

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

Discussion

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

Trial Registration

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

Electronic supplementary material

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

Rehabilitation Technology: Assistance from Hospital to Home

Rehabilitation is essential for disabled people to achieve the highest level of functional independence, reducing or preventing impairments. Nonetheless, this process can be long and expensive. This fact together with the ageing phenomenon has become a critical issue for both clinicians and patients. In this sense, technological solutions may be beneficial since they reduce the costs and increase the number of patients per caregiver, which makes them more accessible. In addition, they provide access to rehabilitation services for those facing physical, financial, and/or attitudinal barriers. This paper presents the state of the art of the assistive rehabilitation technologies for different recovery methods starting from in-person sessions to complementary at-home activities.

The State of Behavior Change Techniques in Virtual Reality Rehabilitation of Neurologic Populations

Background: Neurologic rehabilitation aims to restore function, address barriers to activity, and improve quality of life in those with injury to the nervous system. Virtual reality (VR) has emerged as a useful tool to enhance neurorehabilitation interventions and outcomes. However, the manner in which VR-based neurorehabilitation has been manipulated to optimize outcomes using theory-based frameworks has not been documented. Behavior Change Techniques (BCTs) are described as the smallest active ingredient in an intervention aimed to change behavior via theoretically-proposed pathways. The purpose of this review was to investigate the ways VR is being used in neurorehabilitation to improve upright mobility, and systematically code those VR interventions for active BCTs.

Methods: Keyword searches were performed using database searches of PubMed, SPORTDiscus, and psycINFO. The search yielded 32 studies for inclusion. Coding for BCTs was conducted using the Behavior Change Techniques Taxonomy v1 (BCTTv1).

Results: Behavioral Practice, Graded Tasks, Biofeedback, and Explicit Feedback were the most commonly used BCTs. All studies reported improvements in motor performance outcomes. However, none of the studies investigated the efficacy of each component of their VR intervention making it difficult to point to the most effective components of VR interventions overall.

Conclusions: This review suggests that investigation into the specific components of VR interventions, along with purposeful implementation and reporting of BCTs will help improve understanding of the efficacy of VR as a neurorehabilitation tool. Future research could benefit from incorporating BCTs into the design process of VR interventions to produce optimal rehabilitation potential.

Wearable technologies for active living and rehabilitation: Current research challenges and future opportunities

This paper presents some recent developments in the field of wearable sensors and systems that are relevant to rehabilitation and provides examples of systems with evidence supporting their effectiveness for rehabilitation. A discussion of current challenges and future developments for selected systems is followed by suggestions for future directions needed to advance towards wider deployment of wearable sensors and systems for rehabilitation.

Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review

OBJECTIVE

To investigate the effects of various rehabilitative interventions aimed at enhancing poststroke motor recovery by assessing their effectiveness when compared with no treatment or placebo and their superiority when compared with conventional training program (CTP).

DATA SOURCE

A literature search was based on 19 Cochrane reviews and 26 other reviews. We also updated the searches in PubMed up to September 30, 2017.

STUDY SELECTION

Randomized controlled trials associated with 18 experimented training programs (ETP) were included if they evaluated the effects of the programs on either upper extremity (UE) or lower extremity (LE) motor recovery among adults within 6 months poststroke; included ≥10 participants in each arm; and had an intervention duration of ≥10 consecutive weekdays.

DATA EXTRACTION

Four reviewers evaluated the eligibility and quality of literature. Methodological quality was assessed using the PEDro scale.

DATA SYNTHESIS

Among the 178 included studies, 129 including 7450 participants were analyzed in this meta-analysis. Six ETPs were significantly effective in enhancing UE motor recovery, with the standard mean differences (SMDs) and 95% confidence intervals outlined as follow: constraint-induced movement therapy (0.82, 0.45-1.19), electrostimulation (ES)-motor (0.42, 0.22-0.63), mirror therapy (0.71, 0.22-1.20), mixed approach (0.21, 0.01-0.41), robot-assisted training (0.51, 0.22-0.80), and task-oriented training (0.57, 0.16-0.99). Six ETPs were significantly effective in enhancing LE motor recovery: body-weight-supported treadmill training (0.27, 0.01-0.52), caregiver-mediated training (0.64, 0.20-1.08), ES-motor (0.55, 0.27-0.83), mixed approach (0.35, 0.15-0.54), mirror therapy (0.56, 0.13-1.00), and virtual reality (0.60, 0.15-1.05). However, compared with CTPs, almost none of the ETPs exhibited significant SMDs for superiority.

CONCLUSIONS

Certain experimented interventions were effective in enhancing poststroke motor recovery, but little evidence supported the superiority of experimented interventions over conventional rehabilitation.

Interactive Video Gaming Improves Functional Balance in Poststroke Individuals: Meta-Analysis of Randomized Controlled Trials

The main objective of this study was to evaluate the effects of interactive video games on functional balance and mobility in poststroke individuals. The Health Science databases accessed included Medline via PubMed, LILACS, SciELO, and PEDro. The inclusion criteria were as follows: clinical studies evaluating the use of interactive video games as a treatment to improve functional balance and mobility in individuals poststroke and studies published in the Brazilian Portuguese, English, or Spanish language between 2005 and April 2016. PEDro Scale was used to analyze the methodological quality of the studies. The Berg Balance Scale and Timed Up and Go Test (TUGT) data were evaluated using a meta-analysis, the publication bias was assessed by funnel plots, and the heterogeneity of the studies by I ² statistic. Eleven studies were included in the final analysis. Functional balance improved in individuals treated using interactive video games (mean difference = 2.24, 95% confidence interval [0.45, 4.04], p = .01), but no improvement was observed in mobility as measured by TUGT. The studies presented low heterogeneity (24%). The mean score on the PEDro Scale was 6.2 ± 1.9. Interactive video games were effective in improving functional balance but did not influence the mobility of individuals poststroke.

Virtual Reality Exercise for Anxiety and Depression: A Preliminary Review of Current Research in an Emerging Field

OBJECTIVE

Although current evidence supports the use of virtual reality (VR) in the treatment of mental disorders, it is unknown whether VR exercise would be beneficial to mental health. This review synthesized literature concerning the effect of VR exercise on anxiety and depression among various populations.

METHODS

Ten electronic databases were searched for studies on this topic from January 2000 through October 2017. Studies were eligible if the article: (1) was peer-reviewed; (2) was published in English; and (3) used quantitative measures in assessing anxiety- and depression-related outcomes.

RESULTS

A total of five empirical studies met the eligibility criteria. These studies included two randomized clinical trials, one control trial, and two cross-sectional studies. Four studies reported significant improvements in anxiety- and depression-related measures following VR exercise, including reduced tiredness and tension, in addition to increased energy and enjoyment. Nonetheless, one study failed to support the effectiveness of VR exercise over traditional exercise alone on depressive symptoms.

CONCLUSIONS

Findings favor VR exercise in alleviating anxiety and depression symptomology. However, existing evidence is insufficient to support the advantages of VR exercise as a standalone treatment over traditional therapy in the alleviation of anxiety and depression given the paucity of studies, small sample sizes, and lack of high-quality research designs. Future studies may build upon these limitations to discern the optimal manner by which to employ VR exercise in clinical settings.

Acute Effect of Virtual Reality Exercise Bike Games on College Students' Physiological and Psychological Outcomes

Commercially available virtual reality (VR) exercise systems are extensively used in many health domains among clinical populations. However, evidence regarding the efficacy of this technology on healthy adults' health-related outcomes is unknown. This pilot study compared physiological and psychological responses following exercise on a VR-based exercise bike (VirZoom) and traditional stationary exercise bike. Twelve healthy college students (9 females; M_age = 25.01, SD = ± 4.74; M_BMI = 22.84, SD = ± 3.68) completed two separate 20-minute exercise sessions on the VR-based exercise bike and traditional stationary exercise bike. Blood pressure (BP), ratings of perceived exertion, self-efficacy, and enjoyment were assessed as primary outcomes. Dependent t-tests indicated no significant differences in mean systolic or diastolic BP changes from pre to postexercise between the VR-based exercise and traditional stationary biking sessions (all p > 0.05). Notably, participants reported significantly higher ratings of perceived exertion (p < 0.05, Cohen's d = 0.68) during the traditional exercise biking session compared with VR-based exercise biking session. However, participants had significantly higher self-efficacy (p < 0.05, Cohen's d = -0.83) and enjoyment (p < 0.05, Cohen's d = -0.89) during the VR-based exercise biking session compared with traditional stationary biking. The commercially available VR-based exercise bike (VirZoom) may be considered an effective, enjoyable, and motivating physical activity tool. Further interventions with larger and more diverse samples and examinations of more health-related outcomes are warranted to determine optimal application of VR-based exercise programming among various populations.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of virtual reality-based training with BTs-Nirvana on functional recovery in stroke patients: preliminary considerations

AIM OF THE STUDY

Cognitive impairment occurs frequently in post-stroke patients. This study aimed to determine the effects of a virtual reality training (VRT) with BTs-Nirvana (BTsN) on the recovery of cognitive functions in stroke patients, using the Interactive-Semi-Immersive Program (I-SIP).

MATERIALS AND METHODS

We enrolled 12 subjects (randomly divided into two groups: experimental group (EG); and control group (CG)), who attended the Laboratory of Robotic and Cognitive Rehabilitation of IRCCS Neurolesi of Messina from January to June 2016. The EG underwent a VRT with BTsN, whereas CG received a standard cognitive treatment. Both the groups underwent the same conventional physiotherapy program. Each treatment session lasted 45 minutes and was repeated three times a week for 8 weeks. All the patients were evaluated by a specific clinical-psychometric battery before (T0), immediately (T1), and one month (T2) after the end of the training.

RESULTS

At T1, the EG presented a greater improvement in the trunk control test (p = 0.03), the Montreal Cognitive Assessment (p = 0.01), the selective attention assessment scores (p = 0.01), the verbal memory (p = 0.03), and the visuospatial and constructive abilities (p = 0.01), as compared to CG. Moreover, such amelioration persisted at T2 only in the EG.

CONCLUSIONS

According to these preliminary data, VRT with I-SIP can be considered a useful complementary treatment to potentiate functional recovery, with regard to attention, visual-spatial deficits, and motor function in patients affected by stroke.

A Backward Walking Training Program to Improve Balance and Mobility in Acute Stroke: A Pilot Randomized Controlled Trial

BACKGROUND AND PURPOSE

Strategies to address gait and balance deficits early poststroke are minimal. The postural and motor control requirements of Backward Walking Training (BWT) may provide benefits to improve balance and walking speed in this population. This pilot study (1) determined the feasibility of administering BWT during inpatient rehabilitation and (2) compared the effectiveness of BWT to Standing Balance Training (SBT) on walking speed, balance, and balance-related efficacy in acute stroke.

METHODS

Eighteen individuals 1-week poststroke were randomized to eight, 30-minute sessions of BWT or SBT in addition to scheduled therapy. Five-Meter Walk Test, 3-Meter Backward Walk Test, Activities-Specific Balance Confidence Scale, Berg Balance Scale, Sensory Organization Test, and Function Independence Measure-Mobility were assessed pre- and postintervention and at 3 months poststroke.

RESULTS

Forward gait speed change (BWT: 0.75 m/s; SBT: 0.41 m/s), assessed by the 5-Meter Walk Test, and backward gait speed change (BWT: 0.53 m/s; SBT: 0.23 m/s), assessed by the 3-Meter Backward Walk Test, preintervention to 1-month retention were greater for BWT than for SBT (P < 0.05). Group difference effect size from preintervention to 1-month retention was large for Activities-Specific Balance Confidence Scale, moderate for Berg Balance Scale and Function Independence Measure-Mobility, and small for Sensory Organization Test.

DISCUSSION AND CONCLUSIONS

Individuals 1-week poststroke tolerated 30 min/d of additional therapy. At 1-month postintervention, BWT resulted in greater improvements in both forward and backward walking speed than SBT. Backward walking training is a feasible important addition to acute stroke rehabilitation. Future areas of inquiry should examine BWT as a preventative modality for future fall incidence.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A193).

Virtual reality for stroke rehabilitation

BACKGROUND

Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation with commercial gaming consoles in particular, being rapidly adopted in clinical settings. This is an update of a Cochrane Review published first in 2011 and then again in 2015.

OBJECTIVES

Primary objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity.Secondary objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and seven additional databases. We also searched trials registries and reference lists.

SELECTION CRITERIA

Randomised and quasi-randomised trials of virtual reality ("an advanced form of human-computer interface that allows the user to 'interact' with and become 'immersed' in a computer-generated environment in a naturalistic fashion") in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance and global motor function.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data, and assessed risk of bias. A third review author moderated disagreements when required. The review authors contacted investigators to obtain missing information.

MAIN RESULTS

We included 72 trials that involved 2470 participants. This review includes 35 new studies in addition to the studies included in the previous version of this review. Study sample sizes were generally small and interventions varied in terms of both the goals of treatment and the virtual reality devices used. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains mostly low quality when rated using the GRADE system. Control groups usually received no intervention or therapy based on a standard-care approach.

PRIMARY OUTCOME

results were not statistically significant for upper limb function (standardised mean difference (SMD) 0.07, 95% confidence intervals (CI) -0.05 to 0.20, 22 studies, 1038 participants, low-quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care (providing a higher dose of therapy for those in the intervention group) there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low-quality evidence).

SECONDARY OUTCOMES

when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty-three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild.

AUTHORS' CONCLUSIONS

We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time). There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome. There was a trend suggesting that higher dose (more than 15 hours of total intervention) was preferable as were customised virtual reality programs; however, these findings were not statistically significant.

Does body shadow improve the efficacy of virtual reality-based training with BTS NIRVANA?: A pilot study

BACKGROUND

Aim of the present study was to evaluate whether the presence of body shadows during virtual reality (VR) training with BTS NIRVANA (BTs-N) may lead to a better functional recovery.

METHODS

We enrolled 20 poststroke rehabilitation inpatients, who underwent a neurocognitive-rehabilitative training consisting of 24 sessions (3 times a week for 8 weeks) of BTs-N. All the patients were randomized into 2 groups: semi-immersive virtual training with (S-IVTS group) or without (S-IVT group) body shadows. Each participant was evaluated before (T0) and immediately (T1) after the end of the training (Trial Registration Number: NCT03095560).

RESULTS

The S-IVTS group showed a greater improvement in visuo-constructive skills and sustained attention, as compared with the S-IVT group. The other measures showed nonsignificant within-group and between-group differences.

CONCLUSION

Our results showed that body shadow may represent a high-priority class of stimuli that act by "pushing" attention toward the body itself. Further studies are needed to clarify the role of body shadow in promoting the internal representation construction and thus self-recognition.