Improvement in balance using a virtual reality-based stepping exercise: a randomized controlled trial involving individuals with chronic stroke

Quantifying patient experiences with therapeutic neurorehabilitation technologies: a scoping review

PURPOSE

Neurorehabilitation technologies are a novel approach to providing rehabilitation for patients with neurological conditions. There is a need to explore patient experiences. This study aimed; 1) To identify available questionnaires that assess patients' experiences with neurorehabilitation technologies, and 2) where reported, to document the psychometric properties of the identified questionnaires.

MATERIALS AND METHODS

Four databases were searched (Medline, Embase, Emcare and PsycInfo). The inclusion criteria were all types of primary data collection that included neurological patients of all ages who had experienced therapy with neurorehabilitation technologies and completed questionnaires to assess these experiences.

RESULTS

Eighty-eight publications were included. Fifteen different questionnaires along with many self-developed scales were identified. These were categorised as; 1) self-developed tools, 2) specific questionnaire for a particular technology, and 3) generic questionnaires originally developed for a different purpose. The questionnaires were used to assess various technologies, including virtual reality, robotics, and gaming systems. Most studies did not report any psychometric properties.

CONCLUSION

Many tools have been used to evaluate patient experiences, but few were specifically developed for neurorehabilitation technologies and psychometric data was limited. A preliminary recommendation would be use of the User Satisfaction Evaluation Questionnaire to evaluate patient experience with virtual reality systems.

Telerehabilitation: Exploring the Untapped Potential

Telerehabilitation is a burgeoning field that holds immense promise in revolutionizing the delivery of rehabilitation services. Defined as a branch of telecommunication utilizing technologies such as the internet, it facilitates remote interaction between healthcare providers and patients, transcending geographical barriers. This method proves invaluable in patient assessment, counseling, and treatment across various medical domains, including physical therapy, speech therapy, psychotherapy, and occupational therapy. Particularly beneficial for individuals with disabilities or those unable to access traditional healthcare facilities, telerehabilitation mitigates the constraints of time and cost associated with travel. This paper explores the evolution, types, uses, and research findings in telerehabilitation, shedding light on its transformative potential in health care.

Use of Virtual Reality in Physical Therapy as an Intervention and Diagnostic Tool

Within the past decade, the integration of computer-generated virtual realities (VRs) has witnessed a significant rise in the field of healthcare, particularly in diagnosis and treatment applications. These VR systems have found extensive use in physical therapy, rehabilitation, research, and assessment. This narrative review article is aimed at providing a comprehensive overview of the literature regarding the implementation of VR in the physical therapy profession. The primary objective of this review is to provide information to clinicians about the diverse applications of VR and its potential advantages in intervening across various patient populations and diagnoses during rehabilitation therapy. Through in-depth discussions with experts and a thorough review of pertinent literature, several significant aspects of the topic were identified. Subsequently, we carried out an online search to investigate the prevalent utilization of VR systems within healthcare, both as assessment tools and for therapeutic interventions. Our examination encompassed a total of 56 articles, with supplementary references incorporated as required.

Design of Virtual Reality Exergames for Upper Limb Stroke Rehabilitation Following Iterative Design Methods: Usability Study

BACKGROUND

Since the early 2000s, there has been a growing interest in using exercise video games (exergames) and virtual reality (VR)-based interventions as innovative methods to enhance physical rehabilitation for individuals with multiple disabilities. Over the past decade, researchers and exercise professionals have focused on developing specialized immersive exercise video games for various populations, including those who have experienced a stroke, revealing tangible benefits for upper limb rehabilitation. However, it is necessary to develop highly engaging, personalized games that can facilitate the creation of experiences aligned with the preferences, motivations, and challenges communicated by people who have had an episode of stroke.

OBJECTIVE

This study seeks to explore the customization potential of an exergame for individuals who have undergone a stroke, concurrently evaluating its usability as a technological tool in the realm of physical therapy and rehabilitation.

METHODS

We introduce a playtest methodology to enhance the design of a VR exergame developed using a user-centered approach for upper limb rehabilitation in stroke survivors. Over 4 playtesting sessions, stroke survivors interacted with initial game versions using VR headsets, providing essential feedback for refining game content and mechanics. Additionally, a pilot study involving 10 stroke survivors collected data through VR-related questionnaires to assess game design aspects such as mechanics, assistance, experience, motion sickness, and immersion.

RESULTS

The playtest methodology was beneficial for improving the exergame to align with user needs, consistently incorporating their perspectives and achieving noteworthy results. The pilot study revealed that users had a positive response. In the first scenario, a carpenter presents a game based on the flexion-extension movement of the elbow; the second scenario includes a tejo game (a traditional Colombian throwing game) designed around game mechanics related to the flexion-extension movement of the shoulder; and in the third scenario, a farmer challenges the player to perform a movement combining elbow flexion and extension with internal and external rotation of the shoulder. These findings suggest the potential of the studied exergame as a tool for the upper limb rehabilitation of individuals who have experienced a stroke.

CONCLUSIONS

The inclusion of exergames in rehabilitation for stroke-induced hemiparesis has significantly benefited the recovery process by focusing on essential shoulder and elbow movements. These interactive games play a crucial role in helping users regain mobility and restore practical use of affected limbs. They also serve as valuable data sources for researchers, improving the system's responsiveness. This iterative approach enhances game design and markedly boosts user satisfaction, suggesting exergames have promising potential as adjunctive elements in traditional therapeutic approaches.

A rehabilitative approach beyond the acute stroke event: a scoping review about functional recovery perspectives in the chronic hemiplegic patient

Background

Stroke is a main cause of disability worldwide and its neuro-rehabilitative management is not limited to the acute phase but requires continuity in the rehabilitation approach especially in the chronic phase. The aim of this scoping review was to highlight the different treatment opportunities available in neurorehabilitation, effective for patients with chronic stroke sequelae, not only in terms of maintaining motor function but also improving it.

Methods

The literature search was conducted using the following databases: MEDLINE (PubMed), PEDro, Scopus, Web of Science (WOS), Cochrane from 2012 to February 2023. We selected Randomized Clinical Trials in English dealing with neurorehabilitation strategies in chronic hemiplegic patients after stroke focusing on motor function, muscular strength, gait, postural balance, spasticity, and quality of life.

Results

According to the inclusion criteria, 47 articles were selected for our review. All of them were analyzed following the primary outcome and the rehabilitation technique used. Despite the different protocols used within the same technique and despite the chronicity of the disease, all studies report an improvement after the rehabilitation treatment of motor function and quality of life.

Conclusion

The literature analyzed invites us to reflect respect to neurorehabilitation approach to the patient with chronic stroke sequelae often considered to have as its objective the maintenance of the present motor function and contain disability: instead, the review reports how, even in chronicity, the patient always reports margins of statistically and clinically significant improvement. The chronic stroke rehabilitation over 6 months has been proved effective in obtaining recovery in different settings.

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.

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.

Digital Health Behavioural Interventions to Support Physical Activity and Sedentary Behaviour in Adults after Stroke: A Systematic Literature Review with Meta-Analysis of Controlled Trials

Background: As the global prevalence of stroke continues to rise, it becomes increasingly pressing to investigate digital health behaviour change interventions that promote physical activity and reduce sedentary behaviour for stroke patients to support active lifestyles. Purpose: The primary aim of this study is to investigate the effectiveness of digital health interventions in promoting physical activity and reducing sedentary behaviour for stroke patients. The secondary aim is to investigate the intervention components that explain intervention effectiveness to further inform intervention development and policy making. Methods: A systematic search of the literature was conducted in four databases (Scopus, MEDLINE (PubMed), Web of Science, and PsychINFO) to identify the most robust evidence in the form of randomised controlled trials of digital interventions for patients with stroke. A random-effects meta-analysis were utilized to quantify the intervention effects on behaviour change, and subgroup analyses to characterise intervention effective components. Results: In total, 16 RCTs were deemed eligible and included in the systematic review. Meta-analyses suggested significant improvements in physical activity (SMD = 0.39, 95% CI 0.17, 0.61, N = 326, p < 0.001, I2 = 0%), and reductions in time of sedentary behaviour (SMD= −0.45, 95% CI −0.76, -0.14, N = 167, p = 0.00, I2 = 0%) after stroke. The 10 m walk test for physical activity, and the timed up and go test for sedentary behaviour, were the objective outcome measures in the most effective behavioural change interventions. Subgroup analyses found that most effective interventions were underpinned by theories of self-regulation and utilised interactive functions to engage patients with the processes of behaviour change. Conclusions: Digital self-monitoring behavioural interventions are effective in promoting physical activity for stroke patients in adjunct to usual care clinical practice and rehabilitation programmes. Rigorous studies are required to provide evidence to disentangle the most effective intervention components for preventative practices and rehabilitation programs and to inform policymaking for stroke treatment.

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.

Is virtual reality training superior to conventional treatment in improving lower extremity motor function in chronic hemiplegic patients?

Objectives: This study aims to examine the effect of virtual reality (VR) training, frequently included in rehabilitation programs, on lower extremity functional status, mobility, balance, and walking speed in chronic stroke patients.

Patients and methods: This randomized, controlled study was conducted with 60 chronic stroke patients (26 males, 34 females; mean age: 64.0 years; range, 33 to 80 years) who presented to the physical therapy and rehabilitation outpatient clinic of the Kütahya Health Sciences University Evliya Çelebi Training and Research Hospital between February 2019 and February 2020. The participants were randomized to the VR group and the control group by simple randomization with 1:1 allocation. The VR group received 30 min of VR training and 30 min of conventional physiotherapy, while the control group received 60 min of conventional physiotherapy. The patients were evaluated before and after treatment using the Fugl-Meyer Assessment-Lower Extremity (FMA-LE), Rivermead Mobility Index (RMI), 10-m walk test (10MWT), and Berg Balance Scale (BBS).

Results: The FMA-LE, RMI, 10MWT, and BBS scores significantly improved in both groups after treatment (p<0.001). The post-treatment change in the FMA-LE score was significantly higher in the VR group than in the control group (Z=-3.560, p<0.001). Similarly, the change in the BBS score was significantly higher in the VR group (Z=-3.769, p<0.001). Post-treatment changes in the RMI and 10MWT were not significant (p>0.05).

Conclusion: Virtual reality training combined with conventional physiotherapy was found to be superior to conventional physiotherapy alone in improving lower extremity functional status in chronic stroke patients; therefore, adding a VR component to rehabilitation programs will have a favorable impact on treatment outcomes.

A systematic review on the usability of robotic and virtual reality devices in neuromotor rehabilitation: patients' and healthcare professionals' perspective

BACKGROUND

The application of virtual reality (VR) and robotic devices in neuromotor rehabilitation has provided promising evidence in terms of efficacy, so far. Usability evaluations of these technologies have been conducted extensively, but no overviews on this topic have been reported yet.

METHODS

A systematic review of the studies on patients' and healthcare professionals' perspective through searching of PubMed, Medline, Scopus, Web of Science, CINAHL, and PsychINFO (2000 to 2021) was conducted. Descriptive data regarding the study design, participants, technological devices, interventions, and quantitative and qualitative usability evaluations were extracted and meta-synthetized.

RESULTS

Sixty-eight studies were included. VR devices were perceived as having good usability and as a tool promoting patients' engagement and motivation during the treatment, as well as providing strong potential for customized rehabilitation sessions. By contrast, they suffered from the effect of learnability and were judged as potentially requiring more mental effort. Robotics implementation received positive feedback along with high satisfaction and perceived safety throughout the treatment. Robot-assisted rehabilitation was considered useful as it supported increased treatment intensity and contributed to improved patients' physical independence and psychosocial well-being. Technical and design-related issues may limit the applicability making the treatment difficult and physically straining. Moreover, cognitive and communication deficits were remarked as potential barriers.

CONCLUSIONS

Overall, VR and robotic devices have been perceived usable so far, reflecting good acceptance in neuromotor rehabilitation programs. The limitations raised by the participants should be considered to further improve devices applicability and maximise technological rehabilitation effectiveness.

TRIAL REGISTRATION

PROSPERO registration ref. CRD42021224141 .

Effects of telehealth interventions on performing activities of daily living and maintaining balance in stroke survivors: A systematic review and meta-analysis of randomised controlled studies

BACKGROUND

Stroke is one of the most common causes of disability worldwide. In recent years, diverse telehealth programmes for stroke survivors have suggested that this mode of rehabilitation could improve stroke survivors' abilities to perform activities of daily living (ADLs) and maintain balance. Although increasingly utilised in clinical and community settings, the effectiveness of telehealth interventions in stroke survivors remains inconclusive. This warrants investigation so that telehealth interventions are evidence-based and are not merely modalities of convenience.

AIM

To identify the effects of telehealth interventions on the ability to perform ADLs and maintain balance in stroke survivors.

DESIGN

A systematic literature review and meta-analysis were conducted in accordance with PRISMA guidelines.

METHODS

A systematic literature search was performed using seven databases for literature dated up to April 25, 2021. The revised Cochrane risk of bias tool for randomised trials was used to assess the methodological quality of the included studies. A meta-analysis was performed using a random-effects model to calculate the pooled effects of telehealth interventions. Stata 16.0 was used for the statistical analyses.

RESULTS

A total of 14 studies with 1,367 participants were included in the analysis. Overall, telehealth interventions were effective in improving stroke survivors' abilities to carry out their ADLs (standardised mean difference: .45; 95% confidence interval: .12 to .78); however, no significant effects were found on balance.

CONCLUSION

Telehealth interventions are beneficial for improving stroke survivors' performance of their ADLs. Future telehealth intervention trials should focus on identifying essential intervention delivery components that facilitate intervention adoption by clinicians and stroke survivors and sustain the positive effects on stroke survivors' performance of their ADLs in different settings.

RELEVANCE TO CLINICAL PRACTICE

It is essential to build flexibility in the telehealth-based intervention delivery protocol to meet individual stroke survivors' needs to motivate and enhance their ADL performance.

Effect of 6-Week Balance Exercise by Real-Time Postural Feedback System on Walking Ability for Patients with Chronic Stroke: A Pilot Single-Blind Randomized Controlled Trial

Stroke causes balance dysfunction, leading to decreased physical activity and increased falls. Thus, effective balance exercises are needed to improve balance dysfunction. This single-blind, single-center randomized controlled trial evaluated the long-term and continuous effects of balance exercise using a real-time postural feedback system to improve balancing ability safely. Thirty participants were randomized into intervention (n = 15) and control (n = 15) groups; 11 in each group completed the final evaluation. The effect of the intervention was evaluated by muscle strength of knee extension, physical performance (short physical performance battery, the center of pressure trajectory length per second, and Timed Up and Go test [TUG]), and self-reported questionnaires (modified Gait Efficacy Scale [mGES] and the Fall Efficacy Scale) at pre (0 week), post (6-week), and at follow-up (10-week) visits. The TUG and mGES showed a significant interactive (group * time) effect (p = 0.007 and p = 0.038, respectively). The intervention group showed significant decreasing time to perform TUG from pre- to post-intervention (p = 0.015) and pre-intervention to follow-up (p = 0.016); mGES showed a significant change from pre-intervention to follow-up (p = 0.036). Thus, balance exercise using a real-time postural feedback system can confer a positive effect on the walking ability in patients with chronic stroke and increase their self-confidence in gait performance.

The effect of exercise on balance in patients with stroke, Parkinson, and multiple sclerosis: a systematic review and meta-analysis of clinical trials

BACKGROUND

Stroke, Parkinson, and multiple sclerosis are a range of diseases affecting the nervous system and show balance impairments due to damage of the balance control system. Many early articles have been published on the effect of exercise on balance in patients suffering from neuromuscular diseases. However, a comprehensive study showing a clear result of these three diseases was not found. Hence, the purpose of the present meta-analysis and systematic review is to determine the effect of exercise on balance in people with stroke, Parkinson, and multiple sclerosis.

METHODS

According to the PRISMA 2009 multi-step instructions, keywords related to the purpose of the research were browsed in the MeSH browser databases; IranDoc, MagIran, IranMedex, SID, ScienceDirect, Web of Science (WoS), ProQuest, Medline (PubMed), Scopus, and Google Scholar were searched to extract articles published in Persian and English language. The search process for retrieving the articles in the sources mentioned from January 01, 2000, to December 30, 2020, was done. The heterogeneity index of the studies was determined using the I² test. Given the heterogeneity, the random-effects model was used to combine the articles and the results.

RESULTS

Initially, 7067 articles were found, but after removing duplicate and irrelevant articles, 96 clinical trials with a sample size of the intervention group of 1760 people were included in the study. As a result of the articles' composition, the mean balance score index after exercise in the intervention group showed a significant increase of 0.67 ± 0.12 of the unit (P˂0.01). The highest rate of increase in the balance score after the intervention was reported in patients with myelomeningocele with 1.66 ± 0.3 unit (P˂0.01).

CONCLUSION

Considering the positive effect of using exercise on increasing the balance in patients with stroke, Parkinson, and multiple sclerosis, it is recommended that health care providers implement a regular exercise program to improve the condition of these patients.

Kinect-based rapid movement training to improve balance recovery for stroke fall prevention: a randomized controlled trial

Background

Falls are more prevalent in stroke survivors than age-matched healthy older adults because of their functional impairment. Rapid balance recovery reaction with adequate range-of-motion and fast response and movement time are crucial to minimize fall risk and prevent serious injurious falls when postural disturbances occur. A Kinect-based Rapid Movement Training (RMT) program was developed to provide real-time feedback to promote faster and larger arm reaching and leg stepping distances toward targets in 22 different directions.

Objective

To evaluate the effectiveness of the interactive RMT and Conventional Balance Training (CBT) on chronic stroke survivors’ overall balance and balance recovery reaction.

Methods

In this assessor-blinded randomized controlled trial, chronic stroke survivors were randomized to receive twenty training sessions (60-min each) of either RMT or CBT. Pre- and post-training assessments included clinical tests, as well as kinematic measurements and electromyography during simulated forward fall through a “lean-and-release” perturbation system.

Results

Thirty participants were recruited (RMT = 16, CBT = 14). RMT led to significant improvement in balance control (Berg Balance Scale: pre = 49.13, post = 52.75; P = .001), gait control (Timed-Up-and-Go Test: pre = 14.66 s, post = 12.62 s; P = .011), and motor functions (Fugl-Meyer Assessment of Motor Recovery: pre = 60.63, post = 65.19; P = .015), which matched the effectiveness of CBT. Both groups preferred to use their non-paretic leg to take the initial step to restore stability, and their stepping leg’s rectus femoris reacted significantly faster post-training (P = .036).

Conclusion

The RMT was as effective as conventional balance training to provide beneficial effects on chronic stroke survivors’ overall balance, motor function and improving balance recovery with faster muscle response.

Trial registration: The study was registered at Clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/NCT03183635, NCT03183635) on 12 June 2017.

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.

Effect of Traditional plus Virtual Reality Rehabilitation on Prognosis of Stroke Survivors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Virtual reality (VR) technology has begun to be gradually applied to clinical stroke rehabilitation. The study aims to evaluate the effect of traditional plus VR rehabilitation on motor function recovery, balance, and activities of daily living in stroke patients.

METHOD

Studies published in English prior to October 2020 were retrieved from PubMed, EMBASE, Web of Science, and the Cochrane Library. and used RevMan 5.3 software for meta-analysis.

RESULT

A total of 21 randomized controlled trials (RCTs) were included, which enrolled 619 patients. Traditional plus VR rehabilitation is better than traditional rehabilitation in upper limb motor function recovery measured by Fugl-Meyer Assessment-Upper Extremity (mean difference [MD] 3.49; 95% CI [1.24, 5.73]; P=.002) and manual dexterity assessed by Box & Block Test (MD 6.59; 95% CI [3.45, 9.74]; P<.0001); However, there is no significant difference from traditional rehabilitation in activities of daily living assessed by Functional Independence Measure (MD 0.38; 95% CI [-0.26, 1.02]; P=.25) and balance assessed by Berg Balance Scale (MD 2.18; 95% CI [-0.35, 4.71]; P=.09).

CONCLUSION

Traditional plus VR rehabilitation therapy is an effective method to improve the upper limb motor function and manual dexterity of patients with limb disorders after stroke, and immersive VR rehabilitation treatment may become a new option for rehabilitation after stroke.

Feasibility and effect of interactive telerehabilitation on balance in individuals with chronic stroke: a pilot study

Background

Stroke survivors need continuing exercise intervention to maintain functional status. This study assessed the feasibility and efficacy of an interactive telerehabilitation exergaming system to improve balance in individuals with chronic stroke, compared to conventional one-on-one rehabilitation.

Methods

In this prospective case–control pilot study, 30 Taiwanese individuals with chronic stroke were enrolled and randomly allocated to an experimental group and a control group. All participants received intervention 3 times per week for 4 weeks in the study hospital. The experiment group underwent telerehabilitation using a Kinect camera-based interactive telerehabilitation system in an independent room to simulate home environment. In contrast, the control group received conventional one-on-one physiotherapy in a dedicated rehabilitation area. The effectiveness of interactive telerehabilitation in improving balance in stroke survivors was evaluated by comparing outcomes between the two groups. The primary outcome was Berg Balance Scale (BBS) scores. Secondary outcomes were performance of the Timed Up and Go (TUG) test, Modified Falls Efficacy Scale, Motricity Index, and Functional Ambulation Category.

Results

Comparison of outcomes between experimental and control groups revealed no significant differences between groups at baseline and post-intervention for all outcome measures. However, BBS scores improved significantly in both groups (control group: p = 0.01, effect size = 0.49; experimental group: p = 0.01, effect size = 0.70). Completion times of TUG tests also improved significantly in the experimental group (p = 0.005, effect size = 0.70).

Conclusion

The Kinect camera-based interactive telerehabilitation system demonstrates superior or equal efficacy compared to conventional one-on-one physiotherapy for improving balance in individuals with chronic stroke.

Trial registration ClinicalTrials.gov. NCT03698357. Registered October 4, 2018, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00866-8.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration: NCT04538326.

Smart home R&D system based on virtual reality

Smart home products and equipment are relatively expensive while using specific physical objects to prove functional characteristics, the cost is high, and it is difficult to meet the personal needs of customers. Based on the above background, the purpose of this research is the application and design of a smart home R&D system based on virtual reality. This study proposes the concept of introducing virtual reality methods into the control scene given the shortcomings of the existing smart home control interface interaction methods. From the perspective of being more suitable for the user’s needs, the virtual reality method is used to optimize the smart home interaction methods. Through the analysis of the user’s lifestyle and needs, the functional module model of applying virtual reality to the smart home control scheme is established. Then, by collecting data, use Sketchup software to build and optimize the model of the simulation system to build a realistic family scene model. Finally, through the integrated use of the Unity 3D rendering engine and the virtual simulation system technology, the intelligent simulation of the interior functions of the house is realized. Experimental results show that using virtual reality to optimize the interaction of smart homes, the control method is relatively simple, and the cost can be reduced by about 20%.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

BACKGROUND

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

METHODS

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

RESULTS

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

DISCUSSION

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

LIMITATIONS

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

SUMMARY

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

Early balance training with a computerized stabilometric platform in persons with mild hemiparesis in subacute stroke phase: A randomized controlled pilot study

BACKGROUND

Along with conventional therapy, novel tools are being developed in balance training for the rehabilitation of persons with stroke sequelae. The efficacy of Computerized Balance Training thus far been the object of studies only in persons with chronic stroke.

OBJECTIVE

To investigate the effects of an early Computerized Balance Training on balance, walking endurance and independence in activities of daily living, in persons with mild hemiparesis in subacute phase.

METHODS

Thirty-two persons with a recent hemiparesis (within 4 weeks from stroke onset), able to maintain a standing position for at least 30 seconds, were randomly assigned to an experimental or control group. The control group (CG) were administered conventional physiotherapy of 40 minutes twice a day, 5 times a week for 4 weeks, while the experimental group (EG) underwent conventional physiotherapy 40 minutes once a day and Computerized Balance Training once a day, 5 times a week for 4 weeks. Outcomes were evaluated by means of Berg Balance Scale (BBS), Tinetti Balance Scale (TBS), Two Minutes Walk Test (2MWT), Barthel Index (BI) and stabilometric tests.

RESULTS

Twelve participants for each group completed the training. Each group experienced 8 dropouts. The mean age (years) was 58.1±20.4 for EG and 59.7±14,7 for CG; the days from stroke were respectively 27.9±15.5 and 20±11.7. The difference between the two groups was statistically significant in experimental group for BBS (p = 0.003), for TBS (p = 0.028), for Sensory Integration and Balance tests performed with closed eyes on steady (p = 0.009) or instable surface (p = 0.023). and for 2MWT (p = 0.008).

CONCLUSIONS

Computerized Balance Training is an effective therapeutic tool for balance and gait endurance improvement in persons with stroke in subacute phase.

Estimating Lower Limb Kinematics Using a Lie Group Constrained Extended Kalman Filter with a Reduced Wearable IMU Count and Distance Measurements

Tracking the kinematics of human movement usually requires the use of equipment that constrains the user within a room (e.g., optical motion capture systems), or requires the use of a conspicuous body-worn measurement system (e.g., inertial measurement units (IMUs) attached to each body segment). This paper presents a novel Lie group constrained extended Kalman filter to estimate lower limb kinematics using IMU and inter-IMU distance measurements in a reduced sensor count configuration. The algorithm iterates through the prediction (kinematic equations), measurement (pelvis height assumption/inter-IMU distance measurements, zero velocity update for feet/ankles, flat-floor assumption for feet/ankles, and covariance limiter), and constraint update (formulation of hinged knee joints and ball-and-socket hip joints). The knee and hip joint angle root-mean-square errors in the sagittal plane for straight walking were 7.6±2.6∘ and 6.6±2.7∘, respectively, while the correlation coefficients were 0.95±0.03 and 0.87±0.16, respectively. Furthermore, experiments using simulated inter-IMU distance measurements show that performance improved substantially for dynamic movements, even at large noise levels (σ=0.2 m). However, further validation is recommended with actual distance measurement sensors, such as ultra-wideband ranging sensors.

Effects of exergames training on postural balance in patients who had a chronic stroke: study protocol for a randomised controlled trial

INTRODUCTION

Exergames training, as an additional therapy to standard care, has been widely used for motor recovery after patients who had a stroke, and it is a valuable and positive tool in the rehabilitation of this population. This study describes a single-blind randomised clinical trial that will aim to investigate the effects of exergames training on postural balance in patients with chronic stroke.

METHODS AND ANALYSIS

Forty-two individuals with chronic stroke (>6 months), aged 20-75 years, will be randomised into two groups: the experimental group, which will be subjected to an exergames protocol, and control group, which will undergo a kinesiotherapy protocol. Both protocols are based on postural balance. The intervention will consist of 40-minute sessions two times per week for 10 consecutive weeks. The volunteers will be evaluated before the treatment, at the end of the interventions and 8 weeks thereafter. The primary outcome will be postural balance (Berg Balance Scale, Functional Reach Test, Timed Up and Go test and Centre of Pressure variables) and secondary outcomes will include gait (6 m timed walk and Kinovea Software), cortical activation patterns (electroencephalography Emotiv EPOC), functional independence (Functional Independence Measure), quality of life (Stroke-Specific Quality of Life Scale) and motivation (Intrinsic Motivation Inventory).

ETHICS AND DISSEMINATION

This protocol was approved by the Ethics Committee of the Federal University of Rio Grande do Norte (number 3.434.350). The results of the study will be disseminated to participants through social networks and will be submitted to a peer-reviewed journal and scientific meetings.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (RBR-78v9hx).

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.

Comparison of virtual reality exercise versus conventional exercise on balance in patients with functional ankle instability: A randomized controlled trial

BACKGROUND

Recently, a variety of virtual reality (VR)-based interventions have been studied. However, they were only partially applied to physical therapy.

OBJECTIVE

The present study investigated the effects of a VR exercise program by comparing the results of VR and conventional exercise on balance in patients with functional ankle instability (FAI).

METHODS

Twenty-one participants with symptoms of FAI participated in this study. In the VR training program, the strength and balance exercises were done for 10 minutes each using a program included in the Nintendo Wii Fit Plus for VR intervention. In the conventional program, four ankle strength exercises using the TheraBand and the balance exercises were performed for 10 minutes each. Static and dynamic balance were measured in the overall, anterior-posterior, and medial-lateral directions.

RESULTS

Static balance in the VR exercise was significantly lower in the overall direction than in the conventional exercise. Dynamic balance in the virtual reality exercise was significantly lower than in the conventional exercise at level 2, level 4, and level 8 balance in the medial-lateral direction.

CONCLUSIONS

This study has shown that VR exercise is more effective in the overall direction (static) and medial-lateral direction (dynamic) of balance than conventional method in patients with FAI.

A Framework for Interpretable Full-Body Kinematic Description Using Geometric and Functional Analysis

Rapid advances in cost-effective and non-invasive depth sensors, and the development of reliable and real-time 3D skeletal data estimation algorithms, have opened up a new application area in computer vision - statistical analysis of human kinematic data for fast, automated assessment of body movements. These assessments can play important roles in sports, medical diagnosis, physical therapy, elderly monitoring and related applications. This paper develops a comprehensive geometric framework for quantification and statistical evaluation of kinematic features. The key idea is to avoid analysis of individual joints, as is the current paradigm, and represent movements as temporal evolutions, or trajectories, on shape space of full body skeletons. This allows metrics with appropriate invariance properties to be imposed on these trajectories and leads to definitions of higher-level features, such as spatial symmetry (sS), temporal symmetry (tS), action's velocity (Vl) and body's balance (Bl), during performance of an action. These features exploit skeletal symmetries in space and time, and capture motion cadence to naturally quantify motions of individual subjects. The study of these features as functional data allows us to formulate certain hypothesis tests in feature space. This, in turn, leads to validation of existing assumptions and discoveries of new relationships between kinematics and demographic factors, such as age, gender, and athletic training. We use the clinically validated K3Da kinect dataset to illustrate these ideas, and hope these tools will lead to discovery of new relationships between full-body kinematic features and demographic, health, and wellness factors that are clinically relevant.

Embodiment and Presence in Virtual Reality After Stroke. A Comparative Study With Healthy Subjects

The ability of virtual reality (VR) to recreate controlled, immersive, and interactive environments that provide intensive and customized exercises has motivated its therapeutic use after stroke. Interaction and bodily presence in VR-based interventions is usually mediated through virtual selves, which synchronously represent body movements or responses to events on external input devices. Embodied self-representations in the virtual world not only provide an anchor for visuomotor tasks, but their morphologies can have behavioral implications. While research has focused on the underlying subjective mechanisms of exposure to VR on healthy individuals, the transference of these findings to individuals with stroke is not evident and remains unexplored, which could affect the experience and, ultimately, the clinical effectiveness of neurorehabilitation interventions. This study determined and compared the sense of embodiment and presence elicited by a virtual environment under different perspectives and levels of immersion in healthy subjects and individuals with stroke. Forty-six healthy subjects and 32 individuals with stroke embodied a gender-matched neutral avatar in a virtual environment that was displayed in a first-person perspective with a head-mounted display and in a third-person perspective with a screen, and the participants were asked to interact in a virtual task for 10 min under each condition in counterbalanced order, and to complete two questionnaires about the sense of embodiment and presence experienced during the interaction. The sense of body-ownership, self-location, and presence were more vividly experienced in a first-person than in a third-person perspective by both healthy subjects (p < 0.001, ηp2 = 0.212; p = 0.005, ηp2 = 0.101; p = 0.001, ηp2 = 0.401, respectively) and individuals with stroke (p = 0.019, ηp2 = 0.070; p = 0.001, ηp2 = 0.135; p = 0.014, ηp2 = 0.077, respectively). In contrast, no agency perspective-related differences were found in any group. All measures were consistently higher for healthy controls than for individuals with stroke, but differences between groups only reached statistical significance in presence under the first-person condition (p < 0.010, ηp2 = 0.084). In spite of these differences, the participants experienced a vivid sense of embodiment and presence in almost all conditions. These results provide first evidence that, although less intensively, embodiment and presence are similarly experienced by individuals who have suffered a stroke and by healthy individuals, which could support the vividness of their experience and, consequently, the effectiveness of VR-based interventions.

Improving balance with wobble board exercises in stroke patients: single-blind, randomized clinical trial

Background: A primary objective in stroke rehabilitation is to restore functional balance, in order to reduce falls.Objectives: To identify the efficacy and safety of wobble board exercises when combined with conventional physiotherapy, in improving balance in hemiplegic patients following ischemic strokes.Methods: A block-randomized, controlled, observer blinded, superiority trial was conducted on ambulatory hemiplegic patients following ischemic strokes of middle cerebral artery territory. Subjects in the control group received a conventional physiotherapy regime. Subjects in the intervention group received training on a wobble board combined with conventional physiotherapy. Main Outcome measures were the improvement of Four-Square Step Test (FSST) and the Berg Balance Scale (BBS), both of which assess functional balance at the end of 6 weeks.Results: Thirty patients were randomly assigned for intervention (n = 15) and control (n = 15) groups. One patient dropped out from the study, leaving 29 eligible for the analysis. Intervention and control groups were comparable in sociodemographic characteristics and pre-test scores of balance. A repeated-measures MANOVA showed a significant difference in improvement of balance between the two study groups after 6 weeks [F(1,28) = 32.6,p = .000; Wilk's lambda = .46]. The improvement of mean score of balance in interventional group was greater than in the control group [BBS:9.5 (intervention group),5.5 (control group); FSST:3.9 (intervention group),1.7 (control group)]. There were no injuries in both groups.Conclusions: Wobble board exercises, when combined with the conventional physiotherapy, are safe and effective in restoring functional balance in patients with hemiplegia following ischemic strokes.

Virtual reality applications for chronic conditions management: A review

Background: Virtual Reality (VR) as a computer technology that simulating real environments and situations exploited in numerous healthcare areas such as chronic diseases. The significance of timely treatment and rehabilitation of patients with chronic conditions is high due to the long lasting nature of these conditions. This paper sought to perform a review of published works in the field of VR application in chronic conditions for treatment and rehabilitation purposes.

Methods: We searched the MEDLINE database through PubMed in April 2016 for retrieving published papers from January 2001 to December 2015. From 117 retrieved papers, 52had the inclusion criteria, and their full texts were accessible. Data were extracted from papers based on following items: the name of the first author, year of the study, applied VR methods, type of condition and disease, number of subjects that participated in the study, and finally the status of success and failure of VR application. Data were analyzed using descriptive analysis.

Results: Results of the reviewed investigations have been considered in two main categories including treatment oriented papers (n=38, 73%) while twenty of these papers have been conducted on phobias (53%); also, there are rehabilitation-oriented experiments (n=14, 27%) while thirteen of these papers have been performed on stroke. In 40 papers (77%), the VR technology application reported proper and in 11 papers (21%) the application of VR resulted in relatively proper outcomes and only there is a work (2%) with poor results for VR intervention.

Conclusion: VR technology has been increasingly used in recent years for treatment and rehabilitation purposes among patients affected by chronic conditions in order to motivate them for more successful management.

What is the impact of user affect on motor learning in virtual environments after stroke? A scoping review

PURPOSE

The purported affective impact of virtual reality (VR) and active video gaming (AVG) systems is a key marketing strategy underlying their use in stroke rehabilitation, yet little is known as to how affective constructs are measured or linked to intervention outcomes. The purpose of this scoping review is to 1) explore how motivation, enjoyment, engagement, immersion and presence are measured or described in VR/AVG interventions for patients with stroke; 2) identify directional relationships between these constructs; and 3) evaluate their impact on motor learning outcomes.

METHODS

A literature search was undertaken of VR/AVG interventional studies for adults post-stroke published in Medline, PEDro and CINAHL databases between 2007 and 2017. Following screening, reviewers used an iterative charting framework to extract data about construct measurement and description. A numerical and thematic analytical approach adhered to established scoping review guidelines.

RESULTS

One hundred fifty-five studies were included in the review. Although the majority (89%; N = 138) of studies described at least one of the five constructs within their text, construct measurement took place in only 32% (N = 50) of studies. The most frequently described construct was motivation (79%, N = 123) while the most frequently measured construct was enjoyment (27%, N = 42). A summative content analysis of the 50 studies in which a construct was measured revealed that constructs were described either as a rationale for the use of VR/AVGs in rehabilitation (76%, N = 38) or as an explanation for intervention results (56%, N = 29). 38 (76%) of the studies proposed relational links between two or more constructs and/or between any construct and motor learning. No study used statistical analyses to examine these links.

CONCLUSIONS

Results indicate a clear discrepancy between the theoretical importance of affective constructs within VR/AVG interventions and actual construct measurement. Standardized terminology and outcome measures are required to better understand how enjoyment, engagement, motivation, immersion and presence contribute individually or in interaction to VR/AVG intervention effectiveness.

Classification for Human Balance Capacity Based on Visual Stimulation under a Virtual Reality Environment

The normal and disordered people balance ability classification is a key premise for rehabilitation training. This paper proposes a multi-barycentric area model (MBAM), which can be applied for accurate video analysis based classification. First, we have invited fifty-three subjects to wear an HTC (High Tech Computer Corporation) VIVE (Very Immersive Virtual Experience) helmet and to walk ten meters while seeing a virtual environment. The subjects’ motion behaviors are collected as our balance ability classification dataset. Secondly, we use background differential algorithm and bilateral filtering as the preprocessing to alleviate the video noise and motion blur. Inspired by the balance principle of a tumbler, we introduce a MBAM model to describe the body balancing condition by computing the gravity center of a triangle area, which is surrounded by the upper, middle and lower parts of the human body. Finally, we can obtain the projection coordinates according to the center of gravity of the triangle, and get the roadmap of the subjects by connecting those projection coordinates. In the experiments, we adopt four kinds of metrics (the MBAM, the area variance, the roadmap and the walking speed) innumerical analysis to verify the effect of the proposed method. Experimental results show that the proposed method can obtain a more accurate classification for human balance ability. The proposed research may provide potential theoretical support for the clinical diagnosis and treatment for balance dysfunction patients.

The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic Review and Meta-Analysis

Objective

The aim of this study was to perform a meta-analysis to examine whether virtual reality (VR) training is effective for lower limb function as well as upper limb and overall function in chronic stroke patients.

Methods

Three databases, OVID, PubMed, and EMBASE, were used to collect articles. The search terms used were “cerebrovascular accident (CVA),” “stroke”, and “virtual reality”. Consequently, twenty-one studies were selected in the second screening of meta-analyses. The PEDro scale was used to assess the quality of the selected studies.

Results

The total effect size for VR rehabilitation programs was 0.440. The effect size for upper limb function was 0.431, for lower limb function it was 0.424, and for overall function it was 0.545. The effects of VR programs on specific outcomes were most effective for improving muscle tension, followed by muscle strength, activities of daily living (ADL), joint range of motion, gait, balance, and kinematics.

Conclusion

The VR training was effective in improving the function in chronic stroke patients, corresponding to a moderate effect size. Moreover, VR training showed a similar effect for improving lower limb function as it did for upper limb function.

Effects of Exergame on Patients' Balance and Upper Limb Motor Function after Stroke: A Randomized Controlled Trial

BACKGROUND

Stroke is a major cause of motor incapacity in adults and the elderly population, requiring effective interventions capable of contributing to rehabilitation. Different interventions such as use of exergames are being adopted in the motor rehabilitation and balance area, as they act as motivating instruments, making therapies more pleasurable.

OBJECTIVE

The aim of this study was to investigate the effects of exergame on patients' balance and upper limb motor function after stroke.

METHODS

This study is a randomized controlled trial. Thirty-one participants of both genders, mean age of 76 years, were assigned to the experimental or control groups; the experimental group (n = 16) underwent exergame rehabilitation using Motion Rehab AVE 3D, and the control group (n = 15) underwent conventional physiotherapy. Both EG and GC sessions happened twice a week, for 30 minutes each, over a 12 weeks period, resulting in 24 sessions. All sessions were composed of similar exercises, with same purpose and elapsed time (5 minutes). Instruments applied to verify inclusion criteria were a sociodemographic questionnaire and clinical aspects and a Mini-Mental State Examination. At baseline and after 12 weeks of intervention, the Modified Ashworth Scale, the Fugl-Meyer Assessment, and the Berg Balance Scale were used.

RESULTS

In both groups, patients obtained significant improvement from baseline values in all analyzed variables (shoulder, elbow, and forearm; wrist; hand; and balance) (P < .001). In the intergroup comparison, there were significant differences between the 2 groups for changes in values from preintervention to postintervention of shoulder, elbow and forearm (P = .001), and total (P = .002).

CONCLUSION

Exergame rehabilitation in poststroke patients can be an efficient alternative for restoring balance and upper limb motor function and might even reduce treatment time.

Effects of Virtual Reality Compared to Conventional Therapy on Balance Poststroke: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to systematically review the effect of virtual reality on balance as compared to conventional therapy alone poststroke.

METHODS

The databases of PubMed, Cochrane, and Ovid were searched using select keywords. The randomized controlled trials published between January 2000 and August 2017 in English language were included if they assessed the effect of virtual reality on balance ability compared to conventional therapy alone in adults' poststroke. The Physiotherapy Evidence Database scale was used to assess the methodological quality.

RESULTS

Fourteen papers were included in this review. The experimental groups largely (n = 13) used virtual reality in combination with conventional therapy. Among the high quality studies, significant between-group improvement favoring virtual reality in combination with conventional therapy was found on Berg Balance Scale (n = 7) and Timed Up and Go Scale (n = 7) when compared to conventional therapy alone. The studies were limited by low powered, small sample sizes ranging from 14 to 40, and lack of blinding, concealed allocation, and reporting of missing data. Thirteen homogenous (n = 348, I² = 37.6%, P = .083) studies were included in the meta-analysis using Berg Balance Scale. Significant improvement was observed in the experimental group compared to control group with a medium effect size of .64, confidence interval of .36-.92.

CONCLUSIONS

The findings of this review indicate that virtual reality when combined with conventional therapy is moderately more effective in improving balance than conventional therapy alone in individuals' poststroke.

Intradialytic virtual reality exercise: Increasing physical activity through technology

Intradialytic exercise can improve physical function and health-related quality of life (HRQoL) in hemodialysis (HD) patients, but is not implemented in routine clinical practice. Virtual reality (VR) exercise has resulted in benefits in non-dialysis contexts, but implementation in HD patients has been limited. The aim of this review was to provide an overview of VR, present the results of a 12-week intradialytic VR exercise intervention, and compare VR to conventional exercise. The secondary aim was to review the effect of VR exercise during the last 30 minutes of the HD session on hemodynamic stability. We conclude that VR exercise during HD is safe and can improve physical function and HRQoL, and can be performed safely toward the end of the HD session.

A Game Changer: 'The Use of Digital Technologies in the Management of Upper Limb Rehabilitation'

Hemiparesis is a symptom of residual weakness in half of the body, including the upper extremity, which affects the majority of post stroke survivors. Upper limb function is essential for daily life and reduction in movements can lead to tremendous decline in quality of life and independence. Current treatments, such as physiotherapy, aim to improve motor functions, however due to increasing NHS pressure, growing recognition on mental health, and close scrutiny on disease spending there is an urgent need for new approaches to be developed rapidly and sufficient resources devoted to stroke disease. Fortunately, a range of digital technologies has led to revived rehabilitation techniques in captivating and stimulating environments. To gain further insight, a meta-analysis literature search was carried out using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) method. Articles were categorized and pooled into the following groups; pro/anti/neutral for the use of digital technology. Additionally, most literature is rationalised by quantitative and qualitative findings. Findings displayed, the majority of the inclusive literature is supportive of the use of digital technologies in the rehabilitation of upper extremity following stroke. Overall, the review highlights a wide understanding and promise directed into introducing devices into a clinical setting. Analysis of all four categories; (1) Digital Technology, (2) Virtual Reality, (3) Robotics and (4) Leap Motion displayed varying qualities both-pro and negative across each device. Prevailing developments on use of these technologies highlights an evolutionary and revolutionary step into utilizing digital technologies for rehabilitation purposes due to the vast functional gains and engagement levels experienced by patients. The influx of more commercialised and accessible devices could alter stroke recovery further with initial recommendations for combination therapy utilizing conventional and digital resources.

A Multiparameter Approach to Evaluate Post-Stroke Patients: An Application on Robotic Rehabilitation

Multidomain instrumental evaluation of post-stroke chronic patients, coupled with standard clinical assessments, has rarely been exploited in the literature. Such an approach may be valuable to provide comprehensive insight regarding patients’ status, as well as orienting the rehabilitation therapies. Therefore, we propose a multidomain analysis including clinically compliant methods as electroencephalography (EEG), electromyography (EMG), kinematics, and clinical scales. The framework of upper-limb robot-assisted rehabilitation is selected as a challenging and promising scenario to test the multi-parameter evaluation, with the aim to assess whether and in which domains modifications may take place. Instrumental recordings and clinical scales were administered before and after a month of intensive robotic therapy of the impaired upper limb, on five post-stroke chronic hemiparetic patients. After therapy, all patients showed clinical improvement and presented pre/post modifications in one or several of the other domains as well. All patients performed the motor task in a smoother way; two of them appeared to change their muscle synergies activation strategies, and most subjects showed variations in their brain activity, both in the ipsi- and contralateral hemispheres. Changes highlighted by the new multiparametric instrumental approach suggest a recovery trend in agreement with clinical scales. In addition, by jointly demonstrating lateralization of brain activations, changes in muscle recruitment and the execution of smoother trajectories, the new approach may help distinguish between true functional recovery and the adoption of suboptimal compensatory strategies. In the light of these premises, the multi-domain approach may allow a finer patient characterization, providing a deeper insight into the mechanisms underlying the relearning procedure and the level (neuro/muscular) at which it occurred, at a relatively low expenditure. The role of this quantitative description in defining a personalized treatment strategy is of great interest and should be addressed in future studies.

Biomedical Serious Game System for Balance Rehabilitation of Hemiparetic Stroke Patients

Hemiparetic stroke patients can have several muscular and postural disorders which compromise their balance. Serious games (SG) emerged as a new approach to enhance conventional treatment by making it a motivating method to meet individual needs. This paper evaluated the therapeutic effects of a biomedical SG system developed for balance evaluation and training of hemiparetic stroke patients. The system consists of a balance board with inertial sensors and a computer system that runs the game. A novel scoring system for balance evaluation, which extracts metric information regarding patients' performance while gaming, was proposed. A quasi-experimental study was performed with six hemiparetic patients in an exercise program using the SG twice per week for 10 weeks. Twelve healthy subjects were recruited for determining the baseline score for balance by using the proposed system. Significant effect sizes (ES) were observed for dynamic balance (ES = 0.9), functional mobility (ES = 0.4), and center of pressure displacement of the balance board (ES = 1.9).Significant correlations between game scores and clinical scales suggest that the use of the scoring system for balance evaluation is feasible. The results of this paper support the clinical potential of a biomedical SG for balance rehabilitation of hemiparetic stroke patients.

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

OBJECTIVE

To determine the effect of virtual reality (VR) games on improving balance in different groups of neurological patients with a particular focus on the study quality and to determine the gold standard in VR training in these groups.

MATERIALS AND METHODS

A systematic review of controlled trials published between January 2009 and December 2017 was conducted. The PubMed, SCOPUS, SPORTDiscus, and Medline databases were searched. Studies involved patients with stroke or Parkinson's disease or children with cerebral palsy. The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies.

RESULTS

A total of 20 studies met the inclusion criteria. The PEDro scores ranged from 4 to 8 points. Analysis of the rehabilitation programs revealed a very large discrepancy in the planned volume of exercises in different subgroups of patients.

CONCLUSIONS

Overall, the comparison of VR interventions between conventional rehabilitation and no intervention exhibited significantly better results. However, these results should be interpreted with great caution due to the large diversity of the systems, games, and training volume used in the VR therapy. In all included studies, only several articles included objective methods to assess the effect of VR. In addition, most of the articles showed a high risk of bias, such as a lack of randomization and blinding or a small sample size. That is why further well-designed randomized control trials are required to evaluate the influence of VR on balance in different groups of neurological patients.

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.

Play seriously: Effectiveness of serious games and their features in motor rehabilitation. A meta-analysis

BACKGROUND

Evidence for the effectiveness of serious games (SGs) and their various features is inconsistent in the motor rehabilitation field, which makes evidence based development of SGs a rare practice.

OBJECTIVE

To investigate the effectiveness of SGs in motor rehabilitation for upper limb and movement/balance and to test the potential moderating role of SGs features like feedback, activities, characters and background.

METHODS

We ran a meta-analysis including 61 studies reporting randomized controlled trials (RCTs), controlled trials (CTs) or case series designs in which at least one intervention for motor rehabilitation included the use of SGs as standalone or in combination.

RESULTS

There was an overall moderate effect of SGs on motor indices, d = 0.59, [95% CI, 0.48, 0.71], p <  0.001. Regarding the game features, only two out of 17 moderators were statistically different in terms of effect sizes: type of activity (combination of group with individual activities had the highest effects), and realism of the scenario (fantasy scenarios had the highest effects).

CONCLUSIONS

While we showed that SGs are more effective in improving motor upper limb and movement/balance functions compared to conventional rehabilitation, there were no consistent differences between various game features in their contribution to effects. Further research should systematically investigate SGs features that might have added value in improving effectiveness.

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.

The efficacy of virtual reality assisted versus traditional rehabilitation intervention on individuals with functional ankle instability: a pilot randomized controlled trial

PURPOSE

Virtual reality (VR) training, a virtual environment commonly generated by computer systems, may enhance the therapeutic efficacy of functional rehabilitation programmes. The aim of this study was to investigate the efficacy of a VR assisted intervention (VRAI) versus traditional rehabilitation intervention (TRI) on functional ankle instability (FAI).

METHODS

A single-blind randomized controlled study was conducted with 10 subjects for each group. The VRAI was conducted with the Nintendo Wii Fit Plus, whilst the TRI was conducted with a series of exercises with theraband. The muscle strength change of the two groups and the difference between pre and post interventions for each group were compared.

RESULTS

The VRAI group had less improvement in the muscle strength of all ankle motions than did the TRI group (p > .05). The VRAI group had a greater improvement in muscle strength of plantar flexion than other motions, whilst the TRI group had an improvement in muscle strength of all ankle motions (p < .05).

CONCLUSIONS

The effects of VR training for the condition of FAI were not comparable to conventional training. However, VR training may be added to the conventional training programme as an optional for the condition of FAI. Implications for Rehabilitation Functional ankle instability (FAI) is subjective feelings of ankle instability resulting from proprioceptive and neuromuscular deficits in which individuals may experience "giving way" condition of the ankle. Therapeutic applications of virtual reality (VR) may be comparable to traditional rehabilitation interventions (TRI) in the rehabilitation of individuals with FAI. However, there is no definitive evidence for the issue. Integrating low-cost VR into functional rehabilitation programme can provide insight into an issue of whether it can be replaced with traditional therapeutic approaches. Although, the efficacy of VR application on strengthening muscles is unable to compare to traditional strengthening programmes, it may be considered an optional treatment based on the proprioceptive improvements.

Virtual Reality-Based Center of Mass-Assisted Personalized Balance Training System

Poststroke hemiplegic patients often show altered weight distribution with balance disorders, increasing their risk of fall. Conventional balance training, though powerful, suffers from scarcity of trained therapists, frequent visits to clinics to get therapy, one-on-one therapy sessions, and monotony of repetitive exercise tasks. Thus, technology-assisted balance rehabilitation can be an alternative solution. Here, we chose virtual reality as a technology-based platform to develop motivating balance tasks. This platform was augmented with off-the-shelf available sensors such as Nintendo Wii balance board and Kinect to estimate one’s center of mass (CoM). The virtual reality-based CoM-assisted balance tasks (Virtual CoMBaT) was designed to be adaptive to one’s individualized weight-shifting capability quantified through CoM displacement. Participants were asked to interact with Virtual CoMBaT that offered tasks of varying challenge levels while adhering to ankle strategy for weight shifting. To facilitate the patients to use ankle strategy during weight-shifting, we designed a heel lift detection module. A usability study was carried out with 12 hemiplegic patients. Results indicate the potential of our system to contribute to improving one’s overall performance in balance-related tasks belonging to different difficulty levels.

Time since injury limits but does not prevent improvement and maintenance of gains in balance in chronic stroke

OBJECTIVE

To determine the influence of time since injury on the efficacy and maintenance of gains of rehabilitation of balance after stroke.

METHOD

Forty-seven participants were assigned to a least (6-12 months), a moderate (12-24 months), or a most chronic (>24 months) group. Participants trained for 20 one-hour sessions, administered three to five times a week, combining conventional physical therapy and visual feedback-based exercises that trained the ankle and hip strategies. Participants were assessed before, after the intervention, and one month later with a posturography test (Sway Speed and Limits of Stability) and clinical scales.

RESULTS

In contrast to other subjects, the most chronic participants failed to improve their sway and to maintain the benefits detected in the Limits of Stability after the intervention. Although all the participants improved in those clinical tests that better matched the trained skills, time since injury limited the improvement, and over all, the maintenance of gains.

CONCLUSION

Time since injury limits but does not prevent improvement in chronic stages post-stroke, and this effect appears to be more pronounced with maintaining gains. These findings support that training duration and intensity as well as type of therapy may need to be adjusted based on time post-stroke.

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.