The effects of video game therapy on balance and attention in chronic ambulatory traumatic brain injury: an exploratory study

Virtual Reality-Based Interventions to Improve Balance in Patients with Traumatic Brain Injury: A Scoping Review

INTRODUCTION

Virtual reality (VR)-based interventions to improve balance and mobility are gaining increasing traction across patient populations. VR-based interventions are believed to be more enjoyable and engaging for patients with traumatic brain injury. This scoping review aims to summarize existing studies from the literature that used VR to improve balance and mobility and determine the gap in VR-based balance literature specific to individuals with traumatic brain injury.

METHODS

Two authors independently searched the literature using the search terms "Virtual Reality Traumatic Brain Injury Lower Limb", "Virtual Reality Traumatic Brain Injury Balance", and "Virtual Reality Traumatic Brain Injury Gait".

RESULTS

A total of seventeen studies, specifically, three randomized controlled trials, one one-arm experimental study, two retrospective studies, two case studies, one feasibility/usability study, one cohort study, and seven diagnostic (validation) studies, met the inclusion criteria for this review. The methodological quality of the studies evaluated using the PEDro scale was fair.

DISCUSSION

Future studies should focus on large-scale clinical trials using validated technology to determine its effectiveness and dose-response characteristics. Additionally, standard assessment tools need to be selected and utilized across interventional studies aimed at improving balance and mobility to help compare results between studies.

Occupational Therapy Practice Guidelines for Adults With Traumatic Brain Injury

IMPORTANCE

Occupational therapy practitioners are uniquely qualified to address the occupational needs of people with traumatic brain injury (TBI) and their caregivers to maximize participation, health, and well-being.

OBJECTIVE

These Practice Guidelines are informed by systematic reviews of the effectiveness of interventions that address impairments and skills to improve the occupational performance of people with TBI, as well as interventions for caregivers of people with TBI. The purpose of these guidelines is to summarize the current evidence available to assist clinicians' clinical decision-making in providing interventions for people with TBI and their caregivers.

METHOD

We reviewed six systematic reviews and synthesized the results into clinical recommendations to be used in occupational therapy clinical practice.

RESULTS

Sixty-two articles served as the basis for the clinical recommendations.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence supports multimodal sensory stimulation, unimodal auditory stimulation, physical activity, virtual reality, cognitive interventions, vision therapy, goal-focused interventions, individual and group training and education, and caregiver supports. Occupational therapy practitioners should incorporate these interventions into individual and group sessions to maximize recovery and promote occupational participation. Additional interventions are also available, based on emerging evidence and expert opinion, including prevention approaches, complexity of injury, and the use of occupation-based performance assessments. What This Article Adds: These Practice Guidelines provide a summary of evidence in clinical recommendations tables supporting occupational therapy interventions that address impairments resulting from and skills to improve occupational performance after TBI. The guidelines also include case study examples and evidence graphics for practitioners to use to support clinical reasoning when selecting interventions that address the goals of the person with TBI and their caregiver's needs.

The effect of physical activity on health outcomes in people with moderate-to-severe traumatic brain injury: a rapid systematic review with meta-analysis

BACKGROUND

In 2020, the World Health Organization (WHO) released the first global physical activity and sedentary behaviour guidelines for children and adults living with disability. The evidence informing the guidelines though is not specific to people living with traumatic brain injury (TBI), but rather comes from other disabling conditions such as Parkinson's disease, and stroke. There remains a clear lack of direct evidence of the effects of physical activity for people living with TBI. The objective of this rapid review was to identify direct evidence of the effect of physical activity on health outcomes in people with moderate-to-severe TBI to inform adaptation of the WHO physical activity guidelines into clinical practice guidelines.

METHODS

We conducted a rapid systematic review with meta-analysis of randomised controlled trials, including people of any age with moderate-to-severe TBI, investigating physical activity interventions compared to either usual care, a physical activity intervention with different parameters, or a non-physical activity intervention. Four databases (CENTRAL, SPORTDiscus, PEDro, Ovid MEDLINE) were searched from inception to October 8, 2021. The primary outcomes were physical function, cognition, and quality of life.

RESULTS

Twenty-three studies were included incorporating 812 participants (36% females, majority working-age adults, time post-TBI in studies ranged from 56 days (median) to 16.6 years (mean)). A range of physical activity interventions were evaluated in rehabilitation (n = 12 studies), community (n = 8) and home (n = 3) settings. We pooled data from the end of the intervention for eight outcomes. Participation in a virtual reality physical activity intervention improved mobility, assessed by the Community Balance and Mobility Scale (range 0 to 96; higher score indicates better mobility) more than standard balance training (two studies, 80 participants, Mean Difference = 2.78, 95% CI 1.40 to 4.16; low certainty evidence). There was uncertainty of effect for the remaining outcomes, limited by small sample sizes, diverse comparators and a wide range of outcome measures.

CONCLUSION

This review consolidates the current evidence base for the prescription of physical activity for people with moderate-to-severe TBI. There remains a pressing need for further rigorous research in order to develop practice guidelines to support clinical decision-making when prescribing physical activity in this population.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II: Attention and Information Processing Speed

INTRODUCTION

Moderate to severe traumatic brain injury (MS-TBI) commonly causes disruption in aspects of attention due to its diffuse nature and injury to frontotemporal and midbrain reticular activating systems. Attentional impairments are a common focus of cognitive rehabilitation, and increased awareness of evidence is needed to facilitate informed clinical practice.

METHODS

An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated guidelines for the management of attention in adults, as well as a decision-making algorithm, and an audit tool for review of clinical practice.

RESULTS

This update incorporated 27 studies and made 11 recommendations. Two new recommendations regarding transcranial stimulation and an herbal supplement were made. Five were updated from INCOG 2014 and 4 were unchanged. The team recommends screening for and addressing factors contributing to attentional problems, including hearing, vision, fatigue, sleep-wake disturbance, anxiety, depression, pain, substance use, and medication. Metacognitive strategy training focused on everyday activities is recommended for individuals with mild-moderate attentional impairments. Practice on de-contextualized computer-based attentional tasks is not recommended because of lack of evidence of generalization, but direct training on everyday tasks, including dual tasks or dealing with background noise, may lead to gains for performance of those tasks. Potential usefulness of environmental modifications is also discussed. There is insufficient evidence to support mindfulness-based meditation, periodic alerting, or noninvasive brain stimulation for alleviating attentional impairments. Of pharmacological interventions, methylphenidate is recommended to improve information processing speed. Amantadine may facilitate arousal in comatose or vegetative patients but does not enhance performance on attentional measures over the longer term. The antioxidant Chinese herbal supplement MLC901 (NeuroAiD IITM) may enhance selective attention in individuals with mild-moderate TBI.

CONCLUSION

Evidence for interventions to improve attention after TBI is slowly growing. However, more controlled trials are needed, especially evaluating behavioral or nonpharmacological interventions for attention.

Effectiveness of Vestibular Rehabilitation after Concussion: A Systematic Review of Randomised Controlled Trial

Introduction: Mild traumatic brain injury (mTBI) affects approximately 740 cases per 100,000 people. Impairments related to mTBI include vertigo, dizziness, balance, gait disorders double or blurry vision, and others. The efficacy on acute or chronic phase and dosage of vestibular rehabilitation (VR) in reducing these symptoms is not clearly stated. To clarify these points, we performed a systematic review of randomised controlled trials (RCTs). Methods: A systematic literature search was performed from 2015 to 2022 on PubMed, CINAHL, Cochrane Trial SPORTDiscus, Web of Science, and PEDRO. Eligibility criteria were RCTs which consider VR, participants with mTBI, and no gender or age restriction. Two blinded reviewers independently selected the study, and a third author was contacted in case of disagreements. Risk of bias was independently screened by two authors and successively checked by the other two authors. Results: Thirty-three full articles were read for potential inclusion and seven records met the inclusion criteria. The authors analysed different outcomes considering DHI, a meta-analysis was carried out, statistical difference was observed (p < 0.01), and a mean difference of −6.91 (−9.11, −4.72) in favour of VR was shown. Considering quality of life, the VR group reached a higher score on QOLIBRI. Controversial results were shown about balance and subjective symptoms questionnaire. Differently considering HiMAT, the authors showed a statistically important difference in favour of VR (p = 0.002). Conclusion: VR seems useful to reduce symptoms in patients with concussion; however, a huge heterogeneity of the studies and of the outcomes used were found. Therefore, a larger sample is necessary to assess the efficacy of VR.

A Systematic Review of Treatments of Post-Concussion Symptoms

Approximately 10−20% of patients who have sustained a mild Traumatic Brain Injury (mTBI) show persistent post-concussion symptoms (PCS). This review aims to summarize the level of evidence concerning interventions for PCS. Following the PRISMA guidelines, we conducted a systematic review regarding interventions for PCS post-mTBI until August 2021 using the Medline, Cochrane, and Embase databases. Inclusion criteria were the following: (1) intervention focusing on PCS after mTBI, (2) presence of a control group, and (3) adult patients (≥18 y.o). Quality assessment was determined using the Incog recommendation level, and the risk of bias was assessed using the revised Cochrane risk-of-bias tool. We first selected 104 full-text articles. Finally, 55 studies were retained, including 35 that obtained the highest level of evidence. The risk of bias was high in 22 out of 55 studies. Cognitive training, psycho-education, cognitive behavioral therapy, and graded return to physical activity demonstrated some effectiveness on persistent PCS. However, there is limited evidence of the beneficial effect of Methylphenidate. Oculomotor rehabilitation, light therapy, and headache management using repetitive transcranial magnetic stimulation seem effective regarding somatic complaints and sleep disorders. The preventive effect of early (<3 months) interventions remains up for debate. Despite its limitations, the results of the present review should encourage clinicians to propose a tailored treatment to patients according to the type and severity of PCS and could encourage further research with larger groups.

Virtual reality for balance and mobility rehabilitation following traumatic brain injury: A systematic review of randomized controlled trials

BACKGROUND

Balance and mobility deficits are most prevalent impairments in patients with traumatic brain injury (TBI). The evidence has proposed that rehabilitation plays an important role in improving balance and mobility post-TBI. Virtual reality (VR) is a computer technology that provides immersed users to generate feedback such as visual, audio, and haptic.

OBJECTIVE

This review aimed to examine the effects of the VR treatment intervention on balance and mobility in patients with TBI and to define the most effective VR treatment protocol.

METHODS

SCOPUS, PEDro, PubMed, REHABDATA, EMBASE, and the web of science were searched for experimental trials examining the impacts of VR training on balance and mobility in patients with TBI from inception until July 2022. Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the selected studies.

RESULTS

Five randomized controlled trials (RCTs) met the inclusion criteria. The PEDro scores ranged from 6 to 8, with a median of 6. A total of 157 patients with TBI were included in this review, 31.2% of whom were females. The findings showed that VR intervention is not superior to traditional physiotherapy interventions in improving balance and mobility post- TBI.

CONCLUSIONS

The preliminary findings showed that the influence of VR on the balance and mobility ability in patients with TBI is promising. Combining VR with other concurrent rehabilitation interventions may show more significant improvements in balance and mobility compared to VR interventions alone. The optimal VR treatment protocol remains unclear. Further randomized controlled trials are strongly needed.

Virtual Interventions That Address Motor and Balance Impairments and Skills for Adults With Traumatic Brain Injury (TBI) (2012-2021)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the theme of virtual interventions that address motor and balance impairments and skills for adults with traumatic brain injury.

Feasibility of virtual reality and treadmill training in traumatic brain injury: a randomized controlled pilot trial

OBJECTIVE

To evaluate the safety and efficacy of treadmill training with virtual reality compared to treadmill training alone and standard of care balance and mobility treatment in chronic traumatic brain injury (TBI).

PARTICIPANTS AND DESIGN

Thirty-one individuals with chronic TBI with self-reported and objective balance deficits participated in a 4-week 12 session intervention of treadmill training with virtual reality, treadmill training alone, or standard of care overground therapy.

OUTCOME MEASURES

Primary measures included recruitment and enrollment rates, retention, tolerance to intervention, completeness of outcome measures, and adverse events. Secondary measures included the Community Balance and Mobility Scale, 10 Meter Walk Test, 6 Minute Walk Test, and Timed Up and Go.

RESULTS

No serious adverse events were reported. All participants completed all training sessions and assessments at all time points. Recruitment, enrollment, and retention rates were high. All groups showed a trend toward improvement in all balance and mobility measures following treatment.

CONCLUSION

Virtual reality and treadmill training are safe and feasibile for individuals with TBI. Participants show improvements on balance and mobility measures following a 4-week intervention. Future research is needed to evaluate the efficacy of this intervention compared to other modes of balance and mobility training.

A Systematic Review on Serious Games in Attention Rehabilitation and Their Effects

Attention is a basic and main mental task and can play an important role in the functioning of other brain abilities such as intelligence, memory, learning, and perception, and its deficit occurs in 80% of patients with traumatic brain injury. The use of game-based tools for rehabilitation is rapidly expanding. Cognitive rehabilitation via video games is an emerging hot topic in cognitive science. Serious games serve a specific purpose in addition to entertainment. They can be more engaging than exercises since they replace reward and motivation systems with real-world motivations as a complement for rehabilitation activities. This study was aimed at identifying and categorizing serious computer games used for attention rehabilitation and evaluating their effects. Six electronic databases (Scopus, PubMed, ISI, Embase, IEEE, and Cochrane) were searched in August 2021. The search strategy consisted of three main concepts of “serious game”, “cognitive deficits”, and “cognitive rehabilitation”. The inclusion criteria were (1) journal articles, (2) English language, (3) being published in the last 10 years, (4) human participants, and (5) game-based intervention. In the 30 included studies, 22 unique games were utilized for attention rehabilitation. Lumosity (20%), Brain Age (Dr. Kawashima's Brain Training) (10%), and MoHRS (6.66%) were the most common games among the studies. There were (57%) casual, (23%) action, (10%) simulation, and (10%) multiple genres. Of the 47 tools used in the studies, 5 utilized cross-modal oddball attention tasks, 4 utilized game performance, 3 utilized the paced auditory serial additional test (PASAT), and the rest employed other tools. A total of 73 outcome measures were related to attention, 42 measures did not have significant results, 30 were significantly improved, 1 was significantly deteriorated, and 4 articles did not have any specific measures for attention evaluation. Thus, the results revealed the positive effect of serious games on attention. However, issues such as absence of scientific teams, the variety of the disorders that cause defects, the variety of criteria, differences in measurements, lack of long-term follow-up, insufficient RCT studies, and small sample sizes should be considered when designing, developing, and using game-based systems to prevent bias.

Video game therapy on mobility and dual tasking in multiple sclerosis: study protocol for a randomised controlled trial

INTRODUCTION

Multiple sclerosis (MS) is one of the major causes of disability in young adults and affects mobility, compromising daily living activities and participation in social life. Cognitive domain is also frequently impaired in people with MS (PwMS), particularly the capacity to perform dual-task activities. Impaired cognitive processing abilities need to be treated, and motor and cognitive aspects need to be considered together. Recently, video game therapy (VGT) has been used in rehabilitation to improve motor outcomes and cognitive processing speed. The aim of this study is to test the efficacy of commercially available VGT on mobility and dual tasking in PwMS compared with standardised balance platform training (BPT).

METHODS AND ANALYSIS

This will be a parallel-assignment, double-blinded, randomised control trial. Forty-eight (24 per arm) PwMS with Expanded Disability Status Scale 4-5.5 will be randomly assigned to receive 1 hour training session over 4 weeks (three sessions/week) of either: (1) VGT on commercial video game console to train balance and mobility-related activities or (2) BPT to perform balance, postural stability and weight-shifting exercises with and without visual feedback. The same assessor will evaluate outcome measures at points: before and after the 12 training sessions and at 3 months of follow-up. The primary outcome will be functional mobility, assessed by the Timed Up and Go test. We will also evaluate gait, risk of fall, fatigue and health-related quality of life as well as cognitive and psychological aspects (depression, anxiety and attentional performance) and stability through posturographic evaluation. Dual-tasking assessment will be performed combining posturographic and neuropsychological tests. Data analysis will be performed to compare the efficacy of the two treatments.

ETHICS AND DISSEMINATION

Ethical approval have been granted from the local Ethics Committee. Study results will be communicated through high-quality journals and national and international conferences.

TRIAL REGISTRATION NUMBER

NCT03353974.

Serious games as rehabilitation tools in neurological conditions: A comprehensive review

BACKGROUND

The use of serious games (SG) in rehabilitation has been on the rise in recent years and they are used as either a main interventional tool, or as an adjunct alongside conventional therapies. This is largely due to its virtue of being an electronic platform hence possessing game characteristics that facilitates patient progress.

OBJECTIVE

The present study aimed to provide a comprehensive review of the impact of SG on neurorehabilitation therapies as well as patients' perspectives on rehabilitation.

METHODS

The literature search was conducted in PubMed and Cochrane databases. The study was conducted in four different phases, consisting of the generation of MeSH terms and keywords, screening of articles, and data analysis based on the study characteristics.

RESULTS

This review included 47 studies that explored the use of custom designed experimental serious games (ESG) or commercially designed serious games (CSG) for rehabilitation in a few neurological conditions. The majority of CSG used Nintendo Wii as an adjunct to conventional therapies. Significant improvement in the primary outcomes such as motor functioning, balance, executive and cognitive functions were reported in 35 studies. 17 studies also indicated patient perspectives on rehabilitation. There was no difference between the overall impact of either CSG or ESG.

CONCLUSION

Evidently, SG are efficient exergame tools. However, future studies should explore patient perspectives that could help to design evidence-based games for rehabilitation purposes.

Exergames to Prevent the Secondary Functional Deterioration of Older Adults during Hospitalization and Isolation Periods during the COVID-19 Pandemic

The COVID-19 pandemic is having an intense impact on the functional capacity of older adults, making them more vulnerable to frailty and dependency. The development of preventive and rehabilitative measures which counteract the consequences of confinement or hospitalization is an urgent need. Exergaming can promote physical activity, prevent falls, and maintain functional and cognitive capacity. However, although the use of exergames in health programs for the elderly is promising, their widespread use should not be considered without the supervision of a social health professional. Therefore, the objective of this work was to evaluate and analyze three video game consoles (Nintendo Wii®, Xbox-Kinect® and Play Station 4®) and 26 commercial exergames with the aim of identifying their usefulness for the prevention of functional deterioration. Three occupational therapists analyzed the data independently, and subsequently agreed on the results. The examination of the commercial consoles met three criteria: components, interaction channels and the type of the exergame. Each exergame was analyzed taking into account its ability to train postural control, balance, upper limb functionality and cognitive function. The results of the evaluation showed that exergames contain game activities that can be part of the rehabilitative treatment aimed at the prevention of the functional impairment of older people affected by COVID.

[Physical factors in the rehabilitation of patients after brain injury: a scientometric analysis of evidence-based studies]

OBJECTIVE

Scientometric analysis of evidence-based studies of the physical and rehabilitation medicine (PRM) technologies' effectiveness in the rehabilitation of patients with traumatic brain injury (TBI).

MATERIAL AND METHODS

The search for the material was carried out in electronic databases (PEDro, eLIBRARY, PubMed), as well as databases of systematic reviews (SR) (Cochrane Library) using the keywords: «brain injury», «brain», «physical therapy». RCTs were assessed on the PEDro scale from 1 to 10 points. For the final analysis the results of foreign SRs and RCTs published in the period from January 2014 to December 2019 were selected.

RESULTS

The analysis of studies devoted to the use of therapeutic physical factors in the rehabilitation of patients with TBI from the standpoint of evidence-based medicine is carried out. The basic trends in evidence-based studies on the use of various forms of physical exercise, neuromuscular stimulation, and robot-assisted training in the rehabilitation of patients with TBI are highlighted. PRM technologies have been identified which usage led to positive results in patients with TBI for a number of physiological indicators but the number of evidence-based studies on this topic was insufficient. Based on the scientometric analysis of benign studies the promising directions in the study of the influence of therapeutic physical factors in the rehabilitation of patients with TBI have been identified.

CONCLUSION

The presented data demonstrate the studies' results conducted over the past 5 years on the use of PRM technologies in patients with previous TBI. A significant part of the methods considered in the article is actively used in domestic rehabilitation that reflects the ubiquitous process of integrating information obtained in the course of evidence-based research. In order to improve the quality of rehabilitation care for patients with TBI the practice of analyzing and conducting evidence-based studies on this nosology should be continued.

Enhancing sensory acuity and balance function using near-sensory biofeedback-based perturbation intervention for individuals with traumatic brain injury

BACGROUND

Interventions addressing balance dysfunction after traumatic brain injury (TBI) only target compensatory aspects and do not investigate perceptual mechanisms such as sensory acuity.

OBJECTIVE

To evaluate the efficacy of a novel intervention that integrates sensory acuity with a perturbation-based approach for improving the perception and functional balance after TBI.

METHODS

A two-group design was implemented to evaluate the effect of a novel, perturbation-based balance intervention. The intervention group (n = 5) performed the intervention with the sinusoidal (0.33, 0.5, and 1 Hz) perturbations to the base of support with amplitudes derived using our novel outcome of sensory acuity - perturbation perception threshold (PPT). The efficacy is evaluated using changes in PPT and functional outcomes (Berg Balance Scale (BBS), Timed-up and Go (TUG), 5-meter walk test (5MWT), and 10-meter walk test (10MWT)).

RESULTS

There was a significant post-intervention change in PPT for 0.33 Hz (p = 0.021). Additionally, clinically and statistically significant improvements in TUG (p = 0.03), 5MWT (p = 0.05), and 10MWT (p = 0.04) were observed.

CONCLUSIONS

This study provides preliminary efficacy of a novel, near-sensory balance intervention for individuals with TBI. The use of PPT is suggested for a comprehensive understanding and treatment of balance dysfunction. The promising results support the investigation in a larger cohort.

Effects of technology-supported exercise programs on the knee pain, physical function, and quality of life of individuals with knee osteoarthritis and/or chronic knee pain: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The study sought to examine the effects of technology-supported exercise programs on the knee pain, physical function, and quality of life of individuals with knee osteoarthritis and/or chronic knee pain by a systematic review and meta-analysis of randomized controlled trials.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE, CINAHL Plus, and the Cochrane Library from database inception to August 2020. A meta-analysis and subgroup analyses, stratified by technology type and program feature, were conducted.

RESULTS

Twelve randomized controlled trials were reviewed, all of which implemented the programs for 4 weeks to 6 months. Telephone, Web, mobile app, computer, and virtual reality were used to deliver the programs. The meta-analysis showed that these programs were associated with significant improvements in knee pain (standardized mean difference [SMD] = -0.29; 95% confidence interval [CI], -0.48 to -0.10; P = .003) and quality of life (SMD = 0.25; 95% CI, 0.04 to 0.46; P = .02) but not with significant improvement in physical function (SMD = 0.22; 95% CI, 0 to 0.43; P = .053). Subgroup analyses showed that some technology types and program features were suggestive of potential benefits.

CONCLUSIONS

Using technology to deliver the exercise programs appears to offer benefits. The technology types and program features that were associated with health values have been identified, based on which suggestions are discussed for the further research and development of such programs.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT STATEMENT

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

Evaluating Sensory Acuity as a Marker of Balance Dysfunction After a Traumatic Brain Injury: A Psychophysical Approach

There is limited research on sensory acuity i.e., ability to perceive external perturbations via body-sway during standing in individuals with a traumatic brain injury (TBI). It is unclear whether sensory acuity diminishes after a TBI and if it is a contributing factor to balance dysfunction. The objective of this investigation is to first objectively quantify the sensory acuity in terms of perturbation perception threshold (PPT) and determine if it is related to functional outcomes of static and dynamic balance. Ten individuals with chronic TBI and 11 age-matched healthy controls (HC) performed PPT assessments at 0.33, 0.5, and 1 Hz horizontal perturbations to the base of support in the anterior-posterior direction, and a battery of functional assessments of static and dynamic balance and mobility [Berg balance scale (BBS), timed-up and go (TUG) and 5-m (5MWT) and 10-m walk test (10MWT)]. A psychophysical approach based on Single Interval Adjustment Matrix Protocol (SIAM), i.e., a yes-no task, was used to quantify the multi-sensory thresholds of perceived external perturbations to calculate PPT. A mixed-design analysis of variance (ANOVA) and post-hoc analyses were performed using independent and paired t-tests to evaluate within and between-group differences. Pearson correlation was computed to determine the relationship between the PPT and functional measures. The PPT values were significantly higher for the TBI group (0.33 Hz: 2.97 ± 1.0, 0.5 Hz: 2.39 ± 0.7, 1 Hz: 1.22 ± 0.4) compared to the HC group (0.33 Hz: 1.03 ± 0.6, 0.5 Hz: 0.89 ± 0.4, 1 Hz: 0.42 ± 0.2) for all three perturbation frequencies (p < 0.006 post Bonferroni correction). For the TBI group, the PPT for 1 Hz perturbations showed significant correlation with the functional measures of balance (BBS: r = −0.66, p = 0.037; TUG: r = 0.78, p = 0.008; 5MWT: r = 0.67, p = 0.034, 10MWT: r = 0.76, p = 0.012). These findings demonstrate that individuals with TBI have diminished sensory acuity during standing which may be linked to impaired balance function after TBI.

Effects of physical therapy interventions on balance ability in people with traumatic brain injury: A systematic review

BACKGROUND

Balance deficits are common impairments in individuals with post-traumatic brain injury (TBI). Balance deficits can restrict the activities of daily living and productive participation in social life. To date, no systematic reviews have examined the impact of physical therapy intervention on balance post-TBI.

OBJECTIVE

To examine the effects of physical therapy interventions on balance impairments in individuals with TBI.

METHODS

We systematically searched in PubMed, EMBASE, Scopus, PEDro, MEDLINE, REHABDATA, and Web of Science for randomized controlled trials (RCTs), clinical control trials, and pilot studies that examined the effects of physical therapy interventions on balance deficits in individuals post-TBI. The methodological quality was estimated using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Eight studies published from 2003 to 2019 were included in this study. A total of 259 TBI participants post-TBI were included in this review, 71 (27.41%) of which were females. The methodological quality of the selected studies ranged from low to high. There were no significant differences between experimental interventions, virtual reality (VR), vestibular rehabilitation therapy (VRT), control group interventions, and other traditional physical therapy interventions.

CONCLUSIONS

The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited. Further randomized controlled trials are strongly warranted to understand the role of physical therapy in patients with TBI who complain about balance deficits.

Exergames for balance dysfunction in neurological disability: a meta-analysis with meta-regression

OBJECTIVE

To evaluate systematically the efficacy of exergames for balance dysfunction in neurological conditions and to identify factors of exergaming protocols that may influence their effects.

METHODS

We searched electronic databases for randomized clinical trials investigating the effect of commercial exergames versus alternative interventions on balance dysfunction as assessed by standard clinical scales in adults with acquired neurological disabilities. Standardized mean differences (Hedge's g) were calculated with random-effects models. Subgroup analyses and meta-regression were run to explore potential modifiers of effect size.

RESULTS

Out of 106 screened articles, 41 fulfilled criteria for meta-analysis, with a total of 1223 patients included. Diseases under investigation were stroke, Parkinson's disease, multiple sclerosis, mild cognitive impairment or early Alzheimer's disease, traumatic brain injury, and myelopathy. The pooled effect size of exergames on balance was moderate (g = 0.43, p < 0.001), with higher frequency (number of sessions per week) associated with larger effect (β = 0.24, p = 0.01). There was no effect mediated by the overall duration of the intervention and intensity of a single session. The beneficial effect of exergames could be maintained for at least 4 weeks after discontinuation, but their retention effect was specifically explored in only 11 studies, thus requiring future investigation. Mild to moderate adverse events were reported in a minority of studies. We estimated a low risk of bias, mainly attributable to the lack of double-blindness and not reporting intention-to-treat analysis.

CONCLUSIONS

The pooled evidence suggests that exergames improve balance dysfunction and are safe in several neurological conditions. The findings of high-frequency interventions associated with larger effect size, together with a possible sustained effect of exergaming, may guide treatment decisions and inform future research.

Can exergames contribute to improving walking capacity in older adults? A systematic review and meta-analysis

BACKGROUND

The accessibility, low cost and motivation generated by exergames has fostered its rapid expansion as a rehabilitation technique.

OBJECTIVE

To estimate the effectiveness of rehabilitation programs using IVGT in improving walking capacity of people aged 60 years and over.

MATERIALS AND METHODS

The electronic data research following the PRISMA Statement (Scopus, Cochrane, Web of Science, OT Seeker, National Guideline Clearinghouse, Trip Database, CSIC Spanish National Research Council) was completed in September 2018. The results of randomized clinical trials using exergames for rehabilitation of walking capacity were combined. The calculations have followed the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. The Grading of Recommendations Assessment, Development and Evaluation system was used to evaluate the quality of the evidence.

RESULTS

We obtained data from 14 trials, including 11 meta-analysis studies. The size of exergames effects on walking capacity is moderate, but significant (SMD -0.56; 95 % CI: -0.90, -0.21; p = 0.002). Effectiveness was greater to recover the ability to transfer from one position or place to another (SMD -1.02; CI 95 %: -1.70, -0.35; P = 0.003). The intervention protocols, their duration and intensity varied considerably. The lack of masking, the allocation concealment, the absence of assessor blinding were the main causes of bias so the final grade of evidence has been low for walking and very low for transfers.

CONCLUSIONS

Positive clinical effects of exergames have been found to improve walking capacity, but the quality of evidence to refute its effectiveness is weak with risk of bias. Further research is needed in order to know the actual magnitude of its effect.

Results From a Randomized Controlled Trial to Address Balance Deficits After Traumatic Brain Injury

OBJECTIVE

To evaluate the efficacy of an in-home 12-week physical therapy (PT) intervention that utilized a virtual reality (VR) gaming system to improve balance in individuals with traumatic brain injury (TBI).

SETTING

Home-based exercise program (HEP).

PARTICIPANTS

Individuals (N=63; traditional HEP n=32; VR n=31) at least 1 year post-TBI, ambulating independently within the home, not currently receiving PT services.

MAIN OUTCOME MEASURES

Primary: Community Balance and Mobility Scale (CB&M); Secondary: Balance Evaluation Systems Test (BESTest), Activities-Specific Balance Confidence Scale (ABC), Participation Assessment with Recombined Tools-Objective (PART-O).

RESULTS

No significant between-group differences were observed in the CB&M over the study duration (P=.9983) for individuals who received VR compared to those who received a HEP to address balance deficits after chronic TBI nor in any of the secondary outcomes: BESTest (P=.8822); ABC (P=.4343) and PART-O (P=.8822). However, both groups demonstrated significant improvements in CB&M and BESTest from baseline to 6, 12, and at 12 weeks follow-up (all P's <.001). Regardless of treatment group, 52% of participants met or exceeded the minimal detectable change of 8 points on the CB&M at 24 weeks and 38% met or exceeded the minimal detectable change of 7.81 points on the BESTest.

CONCLUSION

This study did not find that VR training was more beneficial than a traditional HEP for improving balance. However, individuals with chronic TBI in both treatment groups demonstrated improvements in balance in response to these interventions which were completed independently in the home environment.

Effects of Interactive Video Game-Based Exercise on Balance in Diabetic Patients with Peripheral Neuropathy: An Open-Level, Crossover Pilot Study

Purpose. This study evaluated the effects of interactive video game-based (IVGB) exercise on balance in diabetic patients with peripheral neuropathy. Materials and Methods. Twenty-four patients were randomly assigned to two groups (12 participants per group). Group A received IVGB training for the first 6 weeks, with no exercise in the subsequent 6 weeks. Group B had no exercise for the first 6 weeks and then underwent IVGB training in the subsequent 6 weeks. For all participants, the Modified Falls Efficacy Scale (MFES), Time Up and Go (TUG) test, Berg Balance Scale (BBS), and Unipedal Stance Test (UST) were employed at weeks 0, 6, and 12 of the experiment. Results. BBS, right-leg UST, and TUG test scores significantly improved after IVGB intervention, whereas MFES and left-leg UST tended to improve after IVGB intervention. Conclusions. This study revealed that 6-week balance-based exercise training using the IVGB system exerted positive effects on functional balance in patients with diabetic peripheral neuropathy (DPN).

Project Star Catcher

Modern immersive virtual reality experiences have the unique potential to motivate patients undergoing physical therapy for performing intensive repetitive task-based treatment and can be utilized to collect real-time user data to track adherence and compliance rates. This article reports the design and evaluation of an immersive virtual reality game using the HTC Vive for upper limb rehabilitation, titled “Project Star Catcher” (PSC), aimed at users with hemiparesis. The game mechanics were adapted from modified Constraint Induced Therapy (mCIT), an established therapy method where users are asked to use the weaker arm by physically binding the stronger arm. Our adaptation changes the physical to psychological binding by providing various types of immersive stimulation to influence the use of the weaker arm. PSC was evaluated by users with combined developmental and physical impairments as well as stroke survivors. The results suggest that we were successful in providing a motivating experience for performing mCIT as well as a cost-effective solution for real-time data capture during therapy. We conclude the article with a set of considerations for immersive virtual reality therapy game design.