Virtual Reality-Based Assessment for Rehabilitation of the Upper Limb in Patients with Parkinson's Disease: A Pilot Cross-Sectional Study

Background and Objectives: This study aimed to examine the responsiveness and concurrent validity of a serious game and its correlation between the use of serious games and upper limbs (UL) performance in Parkinson's Disease (PD) patients. Materials and Methods: Twenty-four consecutive upper limbs (14 males, 8 females, age: 55-83 years) of PD patients were assessed. The clinical assessment included: the Box and Block test (BBT), Nine-Hole Peg test (9HPT), and sub-scores of the Unified Parkinson's Disease Rating-Scale Motor section (UPDRS-M) to assess UL disability. Performance scores obtained in two different tests (Ex. A and Ex. B, respectively, the Trolley test and Mushrooms test) based on leap motion (LM) sensors were used to study the correlations with clinical scores. Results: The subjective fatigue experienced during LM tests was measured by the Borg Rating of Perceived Exertion (RPE, 0-10); the BBT and 9HPT showed the highest correlation coefficients with UPDRS-M scores (ICCs: -0.652 and 0.712, p < 0.05). Exercise A (Trolley test) correlated with UPDRS-M (ICC: 0.31, p < 0.05), but not with the 9HPT and BBT tests (ICCs: -0.447 and 0.390, p < 0.05), while Exercise B (Mushroom test) correlated with UPDRS-M (ICC: -0.40, p < 0.05), as did these last two tests (ICCs: -0.225 and 0.272, p < 0.05). The mean RPE during LM tests was 3.4 ± 3.2. The evaluation of upper limb performance is feasible and does not induce relevant fatigue. Conclusions: The analysis of the ICC supports the use of Test B to evaluate UL disability and performance in PD patients, while Test A is mostly correlated with disability. Specifically designed serious games on LM can serve as a method of impairment in the PD population.

Facial and upper-limb movement abnormalities in individuals with psychotic-like experiences: a motion analysis study

Slow movements and irregular muscle contraction have been reported separately in different studies targeting individuals with psychotic-like experiences (PLEs). To date, it remains unknown whether these two movement abnormalities, possibly associated with hypo- and hyper-dopaminergia, respectively, co-existed in one sample with PLEs and interrelated in the early stage of psychotic progression. Therefore, this study was to examine if facial and upper-limb slow movements and irregular muscle contraction co-existed in individuals with PLEs, interrelated, and were associated with PLEs. A total of 26 individuals with PLEs, who were identified using the 16-item Prodromal Questionnaire, and 26 age- and gender-matched healthy controls received the facial and upper-limb movement measurement. A motion capture system was used to record the movement procedure and thus calculate kinematic variables that represented severity of slow movements and irregular muscle contraction. Results showed that facial and upper-limb slow movements and facial irregular muscle contraction existed in individuals with PLEs. For the total sample, slower facial movements were associated with less regular facial muscle contraction; slower upper-limb movements were associated with less regular upper-limb muscle contraction. Slower and less regular facial and upper-limb movements were associated with more severe PLEs. Compensatory changes in dopaminergic neural pathways in response to elevated dopamine might explain connection between slow movements and irregular muscle contraction. Because of the ability to detect facial and upper-limb movement abnormalities objectively and sensitively, motion analysis has great applicability to sensorimotor studies for people in the psychosis continuum.

Virtual Reality for Motor and Cognitive Rehabilitation

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

How Cognitive Reserve should Influence Rehabilitation Choices using Virtual Reality in Parkinson’s Disease

Virtual reality (VR) is used in the rehabilitation of patients with Parkinson's disease (PD) in several studies. In VR trials, the motor, physical characteristics, and the degree of the disease are often well defined, while PD cognitive reserve is not. This systematic review was performed to define a cognitive profile for patients with PD who could best benefit from using VR to enhance functional motor aspects during rehabilitation. PubMed, Cochrane Library, Scopus, and Web of Sciences databases were analysed to identify randomized clinical trials (RCT) and randomized pilot trials that addressed the rehabilitation of motor symptoms in subjects with PD using VR. The included studies used Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) to evaluate the cognitive aspect. Only articles written in English and with full texts were considered. The risk of bias from all included studies was assessed based on the Cochrane risk-of-bias tool and the PRISMA guideline was considered. Eighteen articles were eligible for review, including three randomized pilot trials. All studies aimed to evaluate the effect of VR on the motor aspects typically affected by PD (balance, postural control, risk of falls, walking, and reaching). The most widely adopted approach has been nonimmersive VR, except for one study that used immersive VR. Both the benefits of physical activity on the motor symptoms of patients with PD and the impact of cognitive reserve during the rehabilitation of these patients were highlighted. The analysis of the results allowed us to outline the ideal cognitive profile of patients with PD who can benefit from the effects of rehabilitation using VR.

Can behavioural change interventions improve self-efficacy and exercise adherence among people with Parkinson’s? A systematic review protocol

Background :People with Parkinson’s (PwP) have a higher tendency to adopt sedentary lifestyle behaviours and have lower physical activity levels compared to their healthy peers. Previous research has indicated that personal factors including poor outcome expectation and low self-efficacy are stronger predictors of exercise adherence than disease severity. : The purpose of this review is to synthesize the best available evidence on interventions that encompass self-management strategies to overcome barriers to exercise and improve self-efficacy and exercise adherence among PwP.

Methods : The following databases will be searched using a comprehensive search strategy: EBSCO, Medline, CINAHL, Web of Science, PubMed, Embase, Scopus, Google Scholar and Cochrane Library from database inception to 2020. Interventional studies including behavioural change interventions will be included in this review. The title, abstract and full-text screening will be conducted by two independent reviewers. The Joanne Briggs Institute Checklist will be used to assess the quality of each included study. Data will be extracted by two independent reviewers. The outcomes of interest will be self-efficacy outcomes and measures of exercise adherence. A systematic narrative synthesis will be conducted using a framework analysis, applying the Theoretical Domains Framework and Behaviour Change Wheel, producing findings focusing on practice-orientated outcomes. Presentation of data will include tables and text summarizing the characteristics and findings of the eligible studies. Data synthesis and statistical analysis will be performed in Review manager 5.3. The quality of evidence will be reviewed using the GRADE criteria.

Discussion : The review will comprehensively synthesize the  available evidence on interventions to enhance self-efficacy, improve quality of life, physical function,  ultimately improving exercise adherence among PwP and provide invaluable information for healthcare professionals.. This review will make recommendations for appropriate self-management strategies for maximum effect and may have implications for policy and practice regarding enhancing self-efficacy and long-term exercise adherence among PwP.

Systematic review of the application of virtual reality to improve balance, gait and motor function in patients with Parkinson's disease

BACKGROUND

Virtual reality (VR) is an advanced technique used in physical rehabilitation of neurological disorders, however the effects of VR on balance, gait, and motor function in people with Parkinson's (PD) are still debated. Therefore, the systematic review aimed to determine the role of VR on motor function, balance and gait in PD patients.

METHODS

A comprehensive search to identify similar randomised controlled trials was conducted targeting 5 databases including Web of Science, PubMed, CINHAL, Cochrane Library, and Physiotherapy Evidence Database. A total of 25 studies were found eligible for this systematic review, and the methodological assessment of the quality rating of the studies was accomplished using the physiotherapy evidence database scale by 2 authors.

RESULTS

Out of the 25 included studies, 14 studies reported on balance as the primary outcome, 9 studies were conducted to assess motor function, and 12 assessed gait as the primary outcome. Most studies used the Unified Parkinson disease rating scale UPDRS (part-III) for evaluating motor function and the Berg Balance Scale as primary outcome measure for assessing balance. A total of 24 trials were conducted in clinical settings, and only 1 study was home-based VR trainings. Out of 9 studies on motor function, 6 reported equal improvement of motor function as compared to other groups. In addition, VR groups also revealed superior results in improving static balance among patient with PD.

CONCLUSION

This systemic review found that the use of VR resulted in substantial improvements in balance, gait, and motor skills in patients with PD when compared to traditional physical therapy exercises or in combination with treatments other than physical therapy. Moreover, VR can be used as a supportive method for physical rehabilitation in patients of PD. However, the majority of published studies were of fair and good quality, suggesting a demand for high quality research in this area.

Can behavioural change interventions improve self-efficacy and exercise adherence among people with Parkinson’s? A systematic review protocol

Context: People with Parkinson’s (PwP) have a higher tendency to engage in sedentary lifestyle behaviours and have lower physical activity levels compared to their healthy peers. Previous research has indicated that personal factors including poor outcome expectation and low self-efficacy are stronger predictors of exercise adherence than disease severity. Objectives: The purpose of this review is to synthesize the best available evidence on interventions that encompass self-management strategies to overcome barriers to exercise and improve self-efficacy and exercise adherence among PwP. Methods: The following databases will be searched using a comprehensive search strategy: EBSCO, Medline, Cinhal, Web of Science, PubMed, Embase, Scopus, Google Scholar and Cochrane Library from database inception to 2020. The title, abstract and full-text screening will be conducted by two independent reviewers. The Joanne Briggs Institute Checklist will be used to assess the quality of each included study. The quality of evidence will be reviewed using the GRADE criteria. Data will be extracted by two independent reviewers. The outcomes of interest will be self-efficacy outcomes and measures of exercise adherence. A systematic narrative synthesis will be conducted using a framework analysis, applying the Theoretical Domains Framework and Behaviour Change Wheel, producing findings focusing on practice-orientated outcomes. Presentation of data will include tables and text summarizing the characteristics and findings of the eligible studies. Discussion: The review will synthesize the best available evidence on interventions to enhance self-efficacy, improve quality of life, physical function, and ultimately improve exercise adherence among PwP and provide invaluable information for healthcare professionals. The findings of this review will be disseminated through publication in a peer-reviewed journal and presented at relevant conference proceedings. This review will make recommendations for appropriate self-management strategies for maximum effect and may have implications for policy and practice regarding enhancing self-efficacy and long-term exercise adherence among PwP.

An Instrumental Measure of Hand and Facial Movement Abnormalities in Patients With Schizophrenia

INTRODUCTION

Movement disorders have been suggested to be a cardinal component of schizophrenia. With increased research interests in this area, instrumental measures are needed. This study was to examine if the motion capture system was reliable in measuring hand and facial bradykinesia and dyskinesia and more sensitive to detecting movement differences between schizophrenia patients and healthy people than traditional rating scales.

METHODS

Sixteen schizophrenia patients and 20 control subjects were recruited. Hand and facial bradykinesia and dyskinesia were measured using the motion capture system and rated using the Extrapyramidal Symptom Rating Scale and the Abnormal Involuntary Movement Scale.

RESULTS

The system showed strong test-retest reliability and generated larger effect sizes of group differences than did the rating scales.

CONCLUSIONS

The results may support researchers and clinical practitioners to apply the system to sensitively measuring the hand and facial movement symptoms in schizophrenia patients, which contributes to gaining a deep understanding of movement issues in schizophrenia.

The Effects of Virtual Reality, Augmented Reality, and Mixed Reality as Training Enhancement Methods: A Meta-Analysis

OBJECTIVE

The objective of this meta-analysis is to explore the presently available, empirical findings on transfer of training from virtual (VR), augmented (AR), and mixed reality (MR) and determine whether such extended reality (XR)-based training is as effective as traditional training methods.

BACKGROUND

MR, VR, and AR have already been used as training tools in a variety of domains. However, the question of whether or not these manipulations are effective for training has not been quantitatively and conclusively answered. Evidence shows that, while extended realities can often be time-saving and cost-saving training mechanisms, their efficacy as training tools has been debated.

METHOD

The current body of literature was examined and all qualifying articles pertaining to transfer of training from MR, VR, and AR were included in the meta-analysis. Effect sizes were calculated to determine the effects that XR-based factors, trainee-based factors, and task-based factors had on performance measures after XR-based training.

RESULTS

Results showed that training in XR does not express a different outcome than training in a nonsimulated, control environment. It is equally effective at enhancing performance.

CONCLUSION

Across numerous studies in multiple fields, extended realities are as effective of a training mechanism as the commonly accepted methods. The value of XR then lies in providing training in circumstances, which exclude traditional methods, such as situations when danger or cost may make traditional training impossible.

Systemic Literature Review of the Use of Virtual Reality for Rehabilitation in Parkinson Disease

Background

Functional rehabilitation is important when managing Parkinson disease (PD). Virtual reality (VR) therapy is a noninvasive, potential alternative or adjunct to conventional therapies used during rehabilitation.

Observations

The authors searched for articles in Google Scholar, PubMed, Physiotherapy Evidence Database Score (PEDro), and Cochrane after setting specific requirements starting in July 2019. Methodologic quality was assessed by PEDro for randomized controlled trials. Among 89 studies identified, 28 included in this review evaluated VR therapy for use during rehabilitation for PD: 7 used immersive VR and 21 used nonimmersive VR. Among the immersive VR studies, 6 showed improvement in primary outcomes after adding VR therapy. Among the nonimmersive VR studies, 5 showed improvement with VR therapy when compared with conventional therapy, 9 showed improvement with VR and conventional therapy with no between group difference, and the remaining 7 showed improvement in primary outcomes after adding VR intervention. The quality and diversity of studies was a major limitation.

Conclusion

VR therapy is a promising rehabilitation modality for PD but more studies are needed. Additional investigations of VR therapy and PD should include direct comparisons between immersive and nonimmersive VR therapies.

Virtual reality games for rehabilitation of upper extremities in stroke patients

INTRODUCTION

Stroke is one of the main causes of physical disability in which doing frequent and early exercise is imperative for rehabilitation. Virtual reality gaming has a high potential in rehabilitation leading to increased performance of patients. This study aimed to develop, validate and examine virtual reality games in chronic stroke patients.

METHODS

This was a single before-after study. To determine the movements and content of games, 9 physiotherapists and 11 game designers were asked to participate in a questionnaire-based survey. Then, to evaluate the impact of games on rehabilitation, patients (N = 10; mean age = 52 ± 4.38) with chronic stroke were asked to play the games three times a week for four weeks. Outcomes included measurement of the ability to perform shoulder, elbow and wrist movements was performed using goniometric instrument, Modified Motor Assessment Scale (MMAS) was used to assess the functional ability of patients and muscle spasticity, and brunnstrom's stages of recovery test was also used to assess spastic and involuntary muscle movement.

RESULTS

Games have positive effects on the horizontal abduction of shoulder (16.26 ± 23.94, P = 0.02), horizontal adduction of shoulder (59.24 ± 74.76, P = 0.00), supination of wrist (10.68 ± 53.52, P = 0.02), elbow flexion (0.1 ± 1.5, P = 0.00), and wrist flexion (0.06 ± 1.34, P = 0.03). However, they had no effects on the flexion of shoulder, flexion of elbow, extension of elbow, and extension of wrist (p-value> 0.05).

CONCLUSIONS

The results showed that games improve the range of motion of the participants in terms of horizontal abduction and abduction of the shoulder, elbow flexion, and supination and flexion of the wrist. Due to the small sample size in this study, we recommend more studies with larger samples and a control group.

Efficacy of Occupational Therapy Interventions on Quality of Life in Patients with Parkinson's Disease: A Systematic Review and Meta-Analysis

Objective

To review studies assessing the efficacy of occupational therapy interventions on quality of life in patients with Parkinson's disease.

Method

We followed the international guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Databases (PubMed, Physiotherapy Evidence Database, OTsekeer, Scopus, Cinhal, and Web of Science) were searched to identify randomized controlled trials of occupational therapy interventions in patients with Parkinson's disease up to 2019 and with no restriction on language. The primary outcome of the meta-analysis was the evaluation of quality of life following occupational therapy interventions. Because of the heterogeneity of the studies, we examined the data by using a random effect model.

Results

We identified 15 randomized controlled trials that met the inclusion criteria, and 4 of these were included in the meta-analysis. Studies with a follow-up of 2 to 3 months showed that occupational therapy interventions significantly improved the quality of life in patients with Parkinson's disease, with a mean difference of -2.08 (95% confidence interval, -2.52 to -1.64; P < 0.00001). Studies reporting a longer follow-up (6-12 months) also showed that occupational therapy interventions improved the quality of life, with a mean difference of -2.56 (95% confidence interval, -3.52 to -1.61; P < 0.00001).

Conclusion

Different occupational therapy interventions may be effective in improving the quality of life in patients with Parkinson's disease. However, because of the limited number of studies available, the strength of the evidence should be considered moderate.

Exercise Therapies for Parkinson's Disease: A Systematic Review and Meta-Analysis

Recently, rehabilitative exercise therapies have been described as an important method of overcoming the limitations of the conventional therapies for Parkinson's disease. The present study aimed to evaluate efficacy and safety of exercise therapies for Parkinson's disease. Randomized controlled trials that evaluated exercise therapies in patients with Parkinson's disease until December 2016 were searched for in five electronic databases: PubMed, CENTRAL, EMBASE, OASIS, and CNKI. Eighteen studies (1,144 patients) were included. The overall methodological quality was not high. Patients who underwent exercise therapies exhibited statistically significant improvements in the total UPDRS, UPDRS II and III, Berg Balance Scale, preferred walking speed, and Timed Up and Go Test compared to patients who underwent nonexercise therapies. In comparison to patients who performed regular activity, patients who underwent exercise therapies exhibited statistically significant improvements in the total UPDRS, UPDRS II, and UPDRS III. Exercise therapies were found to be relatively safe. Exercise therapies might promote improvements in the motor symptoms of Parkinson's disease. However, due to the small number of randomized controlled trials and methodological limitations, we are unable to draw concrete conclusions. Therefore, further studies with better designs will be needed.

A Virtual Reality-Supported Intervention for Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: Mixed Methods Study

BACKGROUND

The uptake of traditional pulmonary rehabilitation classes by patients with chronic obstructive pulmonary disease (COPD) is poor because of personal factors that prevent accessibility to the venue. Therefore, there is a need for innovative methods of pulmonary rehabilitation, and virtual reality (VR) could be a promising technology for patients with COPD to access services remotely.

OBJECTIVE

This study aimed to investigate whether VR improves compliance with pulmonary rehabilitation among patients with COPD, a particularly vulnerable patient group (Medical Research Council [MRC] 4 or 5), and whether VR provides a credible alternative to traditional pulmonary rehabilitation programs.

METHODS

This was an 8-week patient trial using an innovative VR pulmonary rehabilitation program. A purposive sample of 10 patients with COPD graded MRC 4 or 5 and registered at a selected health care center and a hospital in Cumbria, United Kingdom, were included. Qualitative (focus groups and interviews) data were collected, and to further support the qualitative findings, quantitative data (self-report patient surveys) were gathered before and after the 8-week trial. The 5 self-reported surveys included the Patient Activation Measure, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Short Physical Performance Battery, and the Edmonton Frail Scale.

RESULTS

In a thematic analysis of the qualitative data, 11 themes emerged specific to delivering pulmonary rehabilitation using VR. The quantitative data further support the qualitative findings by revealing significant improvements in all physical measures.

CONCLUSIONS

Overall, this study demonstrates how remotely supervised VR-based pulmonary rehabilitation could help to overcome current issues and limitations associated with providing this service to patients with COPD at scale.

Effects of different types of sensory signals on reaching performance in persons with chronic schizophrenia

Previous studies have reported movement abnormalities in persons with schizophrenia. This study aimed to examine the differences between persons with chronic schizophrenia and healthy control participants in reaching movement and the effects of sensory signals on reaching performance in persons with chronic schizophrenia. A counter-balanced repeated-measures design was employed. Twenty persons with schizophrenia and 20 age- and gender-matched control participants were recruited in this study. Reaching performance was measured in three types of sensory signal conditions (visual, auditory, and no signal), i.e., two externally triggered and one self-initiated movement were assessed in reaction time/inter-response interval, movement time, peak velocity, percentage of time in which peak velocity occurred, and movement units. The results revealed significant main effects of group in reaction time/inter-response interval (p = 0.003), movement time (p < 0.001), peak velocity (p < 0.001), and movement units (p < 0.001). The persons with chronic schizophrenia demonstrated slower response to signals and in self-initiated movement, increased movement time, and less forceful and less smooth movement compared to healthy control participants when performing the reaching task. The interaction effect between group and signal in reaction time/inter-response interval was also significant (p < 0.001). The inter-response interval for self-initiated reaching was the shortest in healthy controls. Conversely, the inter-response interval for self-initiated reaching was the longest in persons with schizophrenia. The main effect of the signal on movement time was significant (p < 0.001). The movement time of reaching was longer in response to the auditory signal than in response to visual or self-initiated. The differences in percentages of time in which peak velocity occurred between persons with schizophrenia and healthy controls (p > 0.01) and across the three conditions (p > 0.01) were non-significant. Neither duration of illness nor antipsychotic dosage was significantly associated with reaching performance (all p > 0.01). In conclusion, these findings indicate that reaching movement in persons with chronic schizophrenia is slower, less forceful, and less coordinated compared to healthy control participants. In addition, persons with chronic schizophrenia also had shorter inter-response interval for self-initiated movement and shorter movement time in auditory signal condition, independent of duration of illness and antipsychotic dosage.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Advantages of using 3D virtual reality based training in persons with Parkinson's disease: a parallel study

BACKGROUND

Parkinson's disease (PD) is a slowly progressive neurodegenerative disease. There are mixed reports on success of physiotherapy in patients with PD. Our objective was to investigate the functional improvements, motivation aspects and clinical effectiveness when using immersive 3D virtual reality versus non-immersive 2D exergaming.

METHODS

We designed a randomized parallel study with 97 patients, but only 20 eligible participants were randomized in 2 groups; the one using 3D Oculus Rift CV1 and the other using a laptop. Both groups participated in the 10-session 3 weeks training with a pick and place task in the virtual world requiring precise hand movement to manipulate the virtual cubes. The kinematics of the hand was traced with Leap motion controller, motivation effect was assessed with modified Intrinsic Motivation Inventory and clinical effectiveness was evaluated with Box & Blocks Test (BBT) and shortened Unified Parkinson's disease rating scale (UPDRS) before and after the training. Mack-Skilling non-parametrical statistical test was used to identify statistically significant differences (p < 0.05) and Cohen's U3 test to find the effect sizes.

RESULTS

Participants in the 3D group demonstrated statistically significant and substantially better performance in average time of manipulation (group x time, p = 0.009), number of successfully placed cubes (group x time, p = 0.028), average tremor (group x time, p = 0.002) and UPDRS for upper limb (U3 = 0.35). The LCD and 3D groups substantially improved their BBT score with training (U3 = 0.7, U3 = 0.6, respectively). However, there were no statistically significant differences in clinical tests between the groups (group x time, p = 0.2189, p = 0.2850, respectively). In addition the LCD group significantly decreased the pressure/tension (U3 = 0.3), the 3D did not show changes (U3 = 0.5) and the differences between the groups were statistically different (p = 0.037). The 3D group demonstrated important increase in effort (U3 = 0.75) and perceived competences (U3 = 0.9).

CONCLUSIONS

The outcomes of the study demonstrated that the immersive 3D technology may bring increased interests/enjoyment score resulting in faster and more efficient functional performance. But the 2D technology demonstrated lower pressure/tension score providing similar clinical progress. A study with much larger sample size may also confirm the clinical effectiveness of the approaches.

TRIAL REGISTRATION

The small scale randomized pilot study has been registered at ClinicalTrials.gov Identifier: NCT03515746 , 4 May 2018.

Effect of virtual reality training on walking distance and physical fitness in individuals with Parkinson's disease

OBJECTIVE

To evaluate the effects of gait training with virtual reality (VR) on walking distance and physical fitness in individuals with Parkinson's Disease (PD).

METHODS

Thirty-seven individuals with PD participated in this prospective, randomized, controlled clinical trial. They were randomly allocated to a control group submitted to conventional training (n = 12), a treadmill group submitted to gait training on a treadmill (n = 13) and a VR group submitted to gait training using the XboxTM (n = 12). Clinical measures, gait variables and the Six-Minute Walk Test (6MWT) were evaluated: pre-intervention, after one intervention session, post-intervention and follow up (30 days after intervention).

RESULTS

The VR and treadmill groups travelled longer distances on the 6MWT and had faster gait speed in comparison to the control group. The VR and treadmill groups demonstrated an increase in pre-6MWT HR. The VR group had more intense HR after the first session and throughout training, but these gains were not maintained at the follow-up.

CONCLUSION

The present findings demonstrate that gait training with a VR program is as effective as treadmill training with regard to gains in walking distance and improvements in temporal gait variables in individuals with PD.

Neurophilosophical and Ethical Aspects of Virtual Reality Therapy in Neurology and Psychiatry

Highly immersive virtual reality (VR) systems have been introduced into the consumer market in recent years. The improved technological capabilities of these systems as well as the combination with biometric sensors, for example electroencephalography (EEG), in a closed-loop hybrid VR-EEG, opens up a range of new potential medical applications. This article first provides an overview of the past and current clinical applications of VR systems in neurology and psychiatry and introduces core concepts in neurophilosophy and VR research (such as agency, trust, presence, and others). Then, important adverse effects of highly immersive VR simulations and the ethical implications of standalone and hybrid VR systems for therapy in neurology and psychiatry are highlighted. These new forms of VR-based therapy may strengthen patients in exercising their autonomy. At the same time, however, these emerging systems present ethical challenges, for example in terms of moral and legal accountability in interactions involving “intelligent” hybrid VR systems. A user-centered approach that is informed by the target patients’ needs and capabilities could help to build beneficial systems for VR therapy.

Mobile Game-based Virtual Reality Program for Upper Extremity Stroke Rehabilitation

Stroke rehabilitation requires repetitive, intensive, goal-oriented therapy. Virtual reality (VR) has the potential to satisfy these requirements. Game-based therapy can promote patients' engagement in rehabilitation therapy as a more interesting and a motivating tool. Mobile devices such as smartphones and tablet PCs can provide personalized home-based therapy with interactive communication between patients and clinicians. In this study, a mobile VR upper extremity rehabilitation program using game applications was developed. The findings from the study show that the mobile game-based VR program effectively promotes upper extremity recovery in patients with stroke. In addition, patients completed two weeks of treatment using the program without adverse effects and were generally satisfied with the program. This mobile game-based VR upper extremity rehabilitation program can substitute for some parts of the conventional therapy that are delivered one-on-one by an occupational therapist. This time-efficient, easy to implement, and clinically effective program would be a good candidate tool for tele-rehabilitation for upper extremity recovery in patients with stroke. Patients and therapists can collaborate remotely through these e-health rehabilitation programs while reducing economic and social costs.

Mobile game-based virtual reality rehabilitation program for upper limb dysfunction after ischemic stroke

BACKGROUND

Virtual reality (VR) has the potential to provide intensive, repetitive, and task-oriented training, and game-based therapy can enhance patients' motivation and enjoyment.

OBJECTIVE

The objective of the present study was to develop a mobile game-based upper extremity VR program for patients who have experienced stroke, and to evaluate the feasibility and effectiveness of the program.

METHODS

This randomized, double-blind, controlled trial included 24 patients with ischemic stroke. The intervention group (n = 12) received 30 min of conventional occupational therapy (OT) and 30 min of the mobile upper extremity rehabilitation program using a smartphone and a tablet PC (MoU-Rehab). The controls (n = 12) received conventional OT alone for 1 h per day. Rehabilitation consisted of 10 sessions of therapy, 5 days per week, for 2 weeks. The outcome measures (Fugl-Meyer Assessment of the upper extremity [FMA-UE], Brunnström stage [B-stage] for the arm and the hand, manual muscle testing [MMT], modified Barthel index [MBI], EuroQol-5 Dimension [EQ-5D], and Beck Depression Inventory [BDI]) were assessed at the beginning and end of treatment, and at 1 month. User satisfaction was evaluated by a questionnaire.

RESULTS

A greater improvement in the FMA-UE, B-stage, and MMT was found after treatment with the MoU-Rehab than with conventional therapy. The extent of improvements in the MBI, EQ-5D, and BDI was not significantly different between the two groups. Patients in the experimental group completed the 2-weeks treatment without adverse effects, and they were generally satisfied with MoU-Rehab.

CONCLUSION

This mobile game-based VR rehabilitation program appears to be feasible and effective for promoting upper limb recovery after ischemic stroke.

A prescription for "nature" - the potential of using virtual nature in therapeutics

Many studies suggest that increased exposure to urban greenness is associated with better population health. Accessing nature can in some circumstances, however, be difficult, especially for individuals with mobility constraints. Therefore, a growing body of work is investigating the ways to replace the in vivo experience with forms of "virtual" contact, in order to provide these individuals with at least some benefits of the natural environment. The aim of this paper is to provide a review of previous use of virtual reality (VR) nature in health and care settings and contemplate the potential use of this technology in future. Our central question is whether engaging with virtual nature can contribute to enhanced physical and emotional well-being in housebound or mobility-constrained individuals. We conclude that while contact with real-world nature is preferred, VR use can be an alternative in cases when in vivo contact with nature is not possible. There are many possibilities for the use of VR technology in psychiatric and medical care; however, the risks, benefits, and cost efficiency of these attempts should be carefully assessed and the outcomes should be measured in a scientifically valid manner. The current review has nonetheless demonstrated that VR nature could play a role in each of the proposed mediating mechanisms linking natural environments and health.

Virtual reality for rehabilitation in Parkinson's disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Cognitive motor intervention for gait and balance in Parkinson's disease: systematic review and meta-analysis

OBJECTIVE

We performed a systematic review and meta-analysis to assess the effect of cognitive motor intervention (CMI) on gait and balance in Parkinson's disease.

DATA SOURCES

PubMed, Embase, Cochrane Library, CINAHL, Web of Science, PEDro, and China Biology Medicine disc.

METHODS

We included randomized controlled trials (RCTs) and non RCTs. Two reviewers independently evaluated articles for eligibility and quality and serially abstracted data. A standardized mean difference ± standard error and 95% confidence interval (CI) was calculated for each study using Hedge's g to quantify the treatment effect.

RESULTS

Nine trials with 181 subjects, four randomized controlled trials, and five single group intervention studies were included. The pooling revealed that cognitive motor intervention can improve gait speed (Hedge's g = 0.643 ± 0.191; 95% CI: 0.269 to 1.017, P = 0.001), stride time (Hedge's g = -0.536 ± 0.167; 95% CI: -0.862 to -0.209, P = 0.001), Berg Balance Scale (Hedge's g = 0.783 ± 0.289; 95% CI: 0.218 to 1.349, P = 0.007), Unipedal Stance Test (Hedge's g = 0.440 ± 0.189; 95% CI: 0.07 to 0.81, P =0.02).

CONCLUSIONS

The systematic review demonstrates that cognitive motor intervention is effective for gait and balance in Parkinson's disease. However, the paper is limited by the quality of the included trials.

Proprioceptive rehabilitation of upper limb dysfunction in movement disorders: a clinical perspective

Movement disorders (MDs) are frequently associated with sensory abnormalities. In particular, proprioceptive deficits have been largely documented in both hypokinetic (Parkinson’s disease) and hyperkinetic conditions (dystonia), suggesting a possible role in their pathophysiology. Proprioceptive feedback is a fundamental component of sensorimotor integration allowing effective planning and execution of voluntary movements. Rehabilitation has become an essential element in the management of patients with MDs, and there is a strong rationale to include proprioceptive training in rehabilitation protocols focused on mobility problems of the upper limbs. Proprioceptive training is aimed at improving the integration of proprioceptive signals using “task-intrinsic” or “augmented feedback.” This perspective article reviews the available evidence on the effects of proprioceptive stimulation in improving upper limb mobility in patients with MDs and highlights the emerging innovative approaches targeted to maximizing the benefits of exercise by means of enhanced proprioception.

[Use of virtual reality in forensic psychiatry. A new paradigm?]

BACKGROUND

For more than 20 years virtual realities (VR) have been successfully used in the assessment and treatment of psychiatric disorders. The most important advantages of VR are the high ecological validity of virtual environments, the entire controllability of virtual stimuli in the virtual environment and the capability to induce the sensation of being in the virtual environment instead of the physical environment. VRs provide the opportunity to face the user with stimuli and situations which are not available or too risky in reality. Despite these advantages VR-based applications have not yet been applied in forensic psychiatry.

OBJECTIVES AND METHODS

On the basis of an overview of the recent state-of-the-art in VR-based applications in general psychiatry, the article demonstrates the advantages and possibilities of VR-based applications in forensic psychiatry.

RESULTS AND CONCLUSIONS

Up to now only preliminary studies regarding the VR-based assessment of pedophilic interests exist. These studies demonstrate the potential of ecologically valid VR-based applications for the assessment of forensically relevant disorders. One of the most important advantages is the possibility of VR to assess the behavior of forensic inpatients in crime-related situations without endangering others. This provides completely new possibilities not only regarding the assessment but also for the treatment of forensic inpatients. Before utilizing these possibilities in the clinical practice exhaustive research and development will be necessary. Given the high potential of VR-based applications, this effort would be worth it.

Does a Wii-based exercise program enhance balance control of independently functioning older adults? A systematic review

Background

Exercise programs that challenge an individual’s balance have been shown to reduce the risk of falls among older adults. Virtual reality computer-based technology that provides the user with opportunities to interact with virtual objects is used extensively for entertainment. There is a growing interest in the potential of virtual reality-based interventions for balance training in older adults. This work comprises a systematic review of the literature to determine the effects of intervention programs utilizing the Nintendo Wii console on balance control and functional performance in independently functioning older adults.

Methods

Studies were obtained by searching the following databases: PubMed, CINAHL, PEDro, EMBASE, SPORTdiscus, and Google Scholar, followed by a hand search of bibliographic references of the included studies. Included were randomized controlled trials written in English in which Nintendo Wii Fit was used to enhance standing balance performance in older adults and compared with an alternative exercise treatment, placebo, or no treatment.

Results

Seven relevant studies were retrieved. The four studies examining the effect of Wii-based exercise compared with no exercise reported positive effects on at least one outcome measure related to balance performance in older adults. Studies comparing Wii-based training with alternative exercise programs generally indicated that the balance improvements achieved by Wii-based training are comparable with those achieved by other exercise programs.

Conclusion

The review indicates that Wii-based exercise programs may serve as an alternative to more conventional forms of exercise aimed at improving balance control. However, due to the great variability between studies in terms of the intervention protocols and outcome measures, as well as methodological limitations, definitive recommendations as to optimal treatment protocols and the potential of such an intervention as a safe and effective home-based treatment cannot be made at this point.

A controlled pilot trial of two commercial video games for rehabilitation of arm function after stroke

Objectives:

To investigate the acceptability and potential efficacy of two commercial video games for improving upper extremity function after stroke in order to inform future sample size and study design.

Design:

A controlled clinical trial design using sequential allocation into groups.

Setting:

A clinical occupational therapy department.

Subjects:

Twenty-four first-stroke patients.

Interventions:

Patients were assigned to one of three groups: conventional group, Wii group, and XaviX group. In addition to regular one-hour conventional rehabilitation, each group received an additional half-hour of upper extremity exercises via conventional devices, Wii games, or XaviX games, for eight weeks.

Main measures:

The Fugl-Meyer Assessment of motor function, Box and Block Test of Manual Dexterity, Functional Independence Measure, and upper extremity range of motion were used at baseline and postintervention. Also, a questionnaire was used to assess motivation and enjoyment.

Results:

The effect size of differences in change scores between the Wii and conventional groups ranged from 0.71 (SD 0.59) to 0.28 (SD 0.58), on the Fugl-Meyer Assessment of motor function ( d = 0.74) was larger than that between the XaviX and conventional groups, ranged from 0.44 (SD 0.49) to 0.28 (SD 0.58) ( d = 0.30). Patient enjoyment was significantly greater in the video game groups (Wii mean 4.25, SD 0.89; XaviX mean 4.38, SD 0.52) than in the conventional group (mean 2.25, SD 0.89, F = 18.55, p < 0.001), but motivation was not significantly different across groups.

Conclusion:

Patients were positive to using video games in rehabilitation. A sample size of 72 patients (24 per group) would be appropriate for a full study.

Trunk-arm coordination in reaching for moving targets in people with Parkinson's disease: comparison between virtual and physical reality

We used a trunk-assisted prehension task to examine the effect of task (reaching for stationary vs. moving targets) and environmental constraints (virtual reality [VR] vs. physical reality) on the temporal control of trunk and arm motions in people with Parkinson's disease (PD). Twenty-four participants with PD and 24 age-matched controls reached for and grasped a ball that was either stationary or moving along a ramp 120% of arm length away. In a similar VR task, participants reached for a virtual ball that was either stationary or moving. Movement speed was measured as trunk and arm movement times (MTs); trunk-arm coordination was measured as onset interval and offset interval between trunk and arm motions, as well as a summarized index-desynchrony score. In both VR and physical reality, the PD group had longer trunk and arm MTs than the control group when reaching for stationary balls (p<.001). When reaching for moving balls in VR and physical reality, however, the PD group had lower trunk and arm MTs, onset intervals, and desynchrony scores (p<.001). For the PD group, VR induced shorter trunk MTs, shorter offset intervals, and lower desynchrony scores than did physical reality when reaching for moving balls (p<.001). These findings suggest that using real moving targets in trunk-assisted prehension tasks improves the speed and synchronization of trunk and arm motions in people with PD, and that using virtual moving targets may induce a movement termination strategy different from that used in physical reality.