Intensive virtual reality and robotic based upper limb training compared to usual care, and associated cortical reorganization, in the acute and early sub-acute periods post-stroke: a feasibility study

Comparative efficacy of robot-assisted therapy associated with other different interventions on upper limb rehabilitation after stroke: A protocol for a network meta-analysis

INTRODUCTION

Post-stroke movement disorders are common, especially upper limb dysfunction, which seriously affects the physical and mental health of stroke patients. With the continuous development of intelligent technology, robot-assisted therapy has become a research hotspot in the upper limb rehabilitation of stroke patients in recent years. Many scholars have also integrated robot-assisted therapy with other interventions to improve rehabilitation outcomes. However, there is a lack of research to determine which auxiliary intervention is the best. Therefore, this protocol aims to guide the development of a network meta-analysis, which helps determine the most suitable auxiliary interventions for robot-assisted therapy.

METHODS AND ANALYSIS

Published randomized controlled trials will be included if robot-assisted therapy or robot-assisted therapy associated with other different interventions was applied in stroke patients with upper limb dysfunction in the experimental group and usual rehabilitation treatment and care was applied in the control group. CINAHL, PubMed, Web of Science, MEDLINE, Embase, CNKI, and Wanfang electronic databases will be searched. Studies should be published between January 1, 2013, and December 31, 2023. Two reviewers will independently select studies and extra data, and assess the quality of the included studies. The risk of bias will be evaluated based on the Cochrane Collaboration's risk of bias tool. The evidence quality will be measured according to the Grading of Recommendations Assessment, Development and Evaluation. A network meta-analysis will be conducted by using STATA version 15.0 and R version 4.1.3. The probabilities of rehabilitation interventions will be ranked according to the surface under the cumulative ranking curve.

ETHICS AND DISSEMINATION

Ethical approval is not needed for reviewing published studies. The results will be submitted to a journal.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023486570.

Virtual reality-based neuroproprioceptive physiotherapy in multiple sclerosis: a protocol for a double-arm randomised assessor-blinded controlled trial on upper extremity function, postural function and quality of life, with molecular and functional MRI assessment

INTRODUCTION

Upper limb (UL) impairment is common in people with multiple sclerosis (pwMS), and functional recovery of the UL is a key rehabilitation goal. Technology-based approaches, like virtual reality (VR), are increasingly promising. While most VR environments are task-oriented, our clinical approach integrates neuroproprioceptive 'facilitation and inhibition' (NFI) principles. To advance this, we developed immersive VR software based on NFI principles targeting UL function and sit-to-stand ability. This study aims to evaluate the effectiveness of this VR therapy compared with conventional NFI-based physical therapy in pwMS. Our study uniquely applies advanced imaging techniques, along with biological molecular assessments, to explore adaptive processes induced by VR rehabilitation.

METHODS AND ANALYSIS

This double-arm, randomised, assessor-blinded, controlled trial runs over 2 months (1 hour, 2 times per week). PwMS with mild to severe disability will receive either VR therapy or real-world physical therapy. Primary outcomes include the nine-hole peg test, box and block test, handgrip strength, tremor and five times sit-to-stand test. Secondary measures include the Multiple Sclerosis Impact Scale, the 5-level EQ-5D questionnaire and kinematic analysis. Adaptive processes will be monitored using imaging techniques (functional MRI and tractography), molecular genetic methods (long non-coding RNAs) and immune system markers (leukocytes, dendritic cells). The International Classification of Functioning, Disability and Health brief set for MS will map the bio-psycho-social context of participants.

ETHICS AND DISSEMINATION

This project and its amendments were approved by the Ethics Committee of the Institute for Clinical and Experimental Medicine and Thomayer Hospital (1983/21+4772/21 (G-21-02) and the Ethics Committee of Kralovske Vinohrady University Hospital (EK-VP/38/0/2021) in Prague, Czechia (with single enrolment). The findings of this project will be disseminated through scientific publications, conferences, professional networks, public engagement, educational materials and stakeholder briefings to ensure a broad impact across clinical, academic and public domains.

TRIAL REGISTRATION NUMBER

clinicaltrials.gov (NCT04807738).

Effect of Virtual Reality-Based Training on Upper Limb Dysfunction during Post-Stroke Rehabilitation: A Meta-Analysis Combined with Meta-Regression

BACKGROUND

Recently, there has been a surge in virtual reality (VR)-based training for upper limb (UL) rehabilitation, which has yielded mixed results. Therefore, we aimed to explore the effects of conventional therapy combined with VR-based training on UL dysfunction during post-stroke rehabilitation.

METHODS

Studies published in English before May 2023 were retrieved from PubMed, Embase, and the Cochrane Library. We also included randomized controlled trials that compared the use of conventional therapy and VR-based training with conventional therapy alone in post-stroke rehabilitation. The meta-analysis was performed using Review Manager Software (version 5.3; The Nordic Cochrane Centre, The Cochrane Collaboration; Copenhagen, Denmark) and Stata/MP 17.0 (StataCorp, LLC, College Station, TX, USA). Univariate and multivariate meta-regression analyses were performed to investigate the effects of stroke duration, VR characteristics, and type of conventional therapy on VR-based training.

RESULTS

In total, 27 randomized controlled trials were included, which enrolled 1354 patients. Our results showed that conventional therapy plus VR-based training is better than conventional therapy alone in UL motor impairment recovery measured using Fugl-Meyer Upper Extremity (standardized mean difference [SMD] = 0.32, 95% confidence interval [CI]: 0.07-0.57, Z = 2.52, p = 0.01). Meta-regression showed that stroke duration had independent effects on Fugl-Meyer Upper Extremity scores of VR-based training in rehabilitation (p = 0.041). Furthermore, in subgroup analysis based on stroke duration, stroke duration >6 months was statistically significant (SMD = 0.20, 95% CI: 0.01-0.39, Z = 2.06, p = 0.04). No relevant publication bias (p = 0.1303), and no significant difference in activity limitation assessed using the Box-Block Test (mean difference [MD] = 2.79, 95% CI: -0.63-6.20, Z = 1.60, p = 0.11) was observed. Regarding the functional independence measured using the Functional Independence Measure scale, studies presented no significant difference between the experimental and control groups (MD = 1.15, 95% CI: -1.84-4.14, Z = 0.76, p = 0.45).

CONCLUSIONS

Conventional therapy plus VR-based training is superior to conventional therapy alone in promoting the recovery of UL motor function after stroke. Therefore, VR-based training may be a potential option for improving UL motor function. The study was registered on PROSPERO (https://www.crd.york.ac.uk/prospero/), registration number: CRD42023472709.

Proportional myoelectric control of a virtual bionic arm in participants with hemiparesis, muscle spasticity, and impaired range of motion

BACKGROUND

This research aims to improve the control of assistive devices for individuals with hemiparesis after stroke by providing intuitive and proportional motor control. Stroke is the leading cause of disability in the United States, with 80% of stroke-related disability coming in the form of hemiparesis, presented as weakness or paresis on half of the body. Current assistive exoskeletonscontrolled via electromyography do not allow for fine force regulation. Current control strategies provide only binary, all-or-nothing control based on a linear threshold of muscle activity.

METHODS

In this study, we demonstrate the ability of participants with hemiparesis to finely regulate their muscle activity to proportionally control the position of a virtual bionic arm. Ten stroke survivors and ten healthy, aged-matched controls completed a target-touching task with the virtual bionic arm. We compared the signal-to-noise ratio (SNR) of the recorded electromyography (EMG) signals used to train the control algorithms and the task performance using root mean square error, percent time in target, and maximum hold time within the target window. Additionally, we looked at the correlation between EMG SNR, task performance, and clinical spasticity scores.

RESULTS

All stroke survivors were able to achieve proportional EMG control despite limited or no physical movement (i.e., modified Ashworth scale of 3). EMG SNR was significantly lower for the paretic arm than the contralateral nonparetic arm and healthy control arms, but proportional EMG control was similar across conditions for hand grasp. In contrast, proportional EMG control for hand extension was significantly worse for paretic arms than healthy control arms. The participants' age, time since their stroke, clinical spasticity rate, and history of botulinum toxin injections had no impact on proportional EMG control.

CONCLUSIONS

It is possible to provide proportional EMG control of assistive devices from a stroke survivor's paretic arm. Importantly, information regulating fine force output is still present in muscle activity, even in extreme cases of spasticity where there is no visible movement. Future work should incorporate proportional EMG control into upper-limb exoskeletons to enhance the dexterity of stroke survivors.

Effects of virtual reality-based robot therapy combined with task-oriented therapy on upper limb function and cerebral cortex activation in patients with stroke

BACKGROUND

This study aimed to investigate the effects of virtual reality (VR)-based robot therapy combined with task-oriented therapy on cerebral cortex activation and upper limb function in patients with stroke.

METHODS

This study included 46 patients with hemiplegia within 1 year of stroke onset. Patients were divided into an experimental group (n = 23) and a control group (n = 23) using a computer randomization program. The experimental group received VR-based robot and task-oriented therapies, whereas the control group received only task-oriented therapy. All participants received interventions for 40 minutes per session, 5 times a week, for 8 weeks. For the pre- and post-evaluation of all participants, the Fugl-Meyer Assessment for the upper extremity, manual function test, motor activity log, and Jebsen-Taylor Hand Function Test were used to evaluate changes in upper limb function and motor-evoked potential amplitudes were measured to compare cerebral cortex activation.

RESULTS

In comparison to the control group, experimental group demonstrated an improvement in the function of the upper limb (P < .01) and activation of the cerebral cortex (P < .01).

CONCLUSION

The combined intervention of VR-based robot and task-oriented therapies is valuable for improving upper limb function and cerebral cortex activation in patients with stroke.

Feasibility and efficacy of an early sensory-motor rehabilitation program on hand function in patients with stroke: a pilot, single-subject experimental design

OBJECTIVE

Hand and upper limb functional impairments following stroke lead to limitations in performing activities of daily living. We aimed to investigate feasibility and efficacy of an early sensory-motor rehabilitation program on hand and upper limb function in patients with acute stroke.

DESIGN

A pilot, single-subject experimental, A-B-A study.

SETTING

Stroke unit of an educational hospital and an outpatient occupational therapy clinic.

PARTICIPANTS

A convenience sample including five people with acute stroke.

PROCEDURES

Participants received 3 h of an intensive hand and upper limb sensory and motor rehabilitation program, 5 days per week for 3 months (15-min mental imagery, 15-min action observation, 30-min mirror therapy, 1.5-h constraint-induced movement therapy, and 30-min bilateral arm training). Activities were chosen based on the task-oriented occupational therapy approach.

OUTCOME MEASURES

An assessor blinded to intervention program measured sensory and motor functions using action research arm test, box and block test, Semmes-Weinstein monofilaments, and upper extremity section of Fugl-Meyer assessment.

RESULTS

Assessment data points in intervention and follow-up phases compared to baseline were in higher levels, sloped upwardly, and increased significantly for all participants in all outcome measures.

CONCLUSIONS

The present pilot study showed that a package of nowadays evidence-based rehabilitation methods including mental imagery, action observation, mirror therapy, modified constraint-induced movement therapy, bilateral arm training, and task-oriented occupational therapy approach is able to improve sensory and motor functions of the hand and upper limb in patients with acute stroke.

Clinical potential and neuroplastic effect of targeted virtual reality based intervention for distal upper limb in post-stroke rehabilitation: a pilot observational study

PURPOSE

A library of Virtual Reality (VR) tasks has been developed for targeted post-stroke rehabilitation of distal upper extremities. The objective of this pilot study was to evaluate the clinical potential of the targeted VR-based therapeutic intervention in a small cohort of patients specifically with chronic stroke. Furthermore, our aim was to explore the possible neuronal reorganizations in corticospinal pathways in response to the distal upper limb targeted VR-intervention.

METHODOLOGY

Five patients with chronic stroke were enrolled in this study and were given VR-intervention of 20 sessions of 45 min each. Clinical Scales, cortical-excitability measures (using Transcranial Magnetic Stimulation): Resting Motor Threshold (RMT), and Motor Evoked Potential (MEP) amplitude, task-specific performance metrics i.e., Time taken to complete the task (TCT), smoothness of trajectory, relative % error were evaluated pre- and post-intervention to evaluate the intervention-induced improvements.

RESULTS

Pre-to post-intervention improvements were observed in Fugl-Meyer Assessment (both total and wrist/hand component), Modified Barthel Index, Stroke Impact Scale, Motor Assessment Scale, active range of motion at wrist, and task-specific outcome metrics. Pre-to post-intervention ipsilesional RMT reduced (mean ∼9%) and MEP amplitude increased (mean ∼29µV), indicating increased cortical excitability at post-intervention.

CONCLUSION

VR-training exhibited improved motor outcomes and cortical-excitability in patients with stroke. Neurophysiological changes observed in terms of improved cortical-excitability might be a consequence of plastic reorganization induced by VR-intervention.

360° immersive virtual reality-based mirror therapy for upper extremity function and satisfaction among stroke patients: a randomized controlled trial

BACKGROUND

Stroke is a leading cause of long-term disability worldwide; therefore, an effective rehabilitation strategy is fundamental. Mirror therapy (MT) has been a popular approach for upper extremity rehabilitation, but it presents some limitations. Recent advancements in virtual reality (VR) technology have introduced immersive VR-based MT, potentially overcoming these limitations and enhancing rehabilitation outcomes.

AIM

This study aimed to evaluate the effectiveness of a novel 360° immersive virtual reality-based MT (360MT) in upper extremity rehabilitation for stroke patients, comparing it to traditional MT (TMT) and conventional physical therapy control group (CG).

DESIGN

A prospective, active control, assessor blinded, parallel groups, randomized controlled trial.

POPULATION

Forty-five participants with chronic stroke within six months of onset.

METHODS

The participants were randomly allocated to 360MT, TMT, or CG groups. Outcome measures included Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Box and Block Test (BBT), and Manual Function Test (MFT). Additionally, patient experience and satisfaction in the groups of 360MT and TMT were assessed through questionnaires and interviews.

RESULTS

Results revealed that the 360MT group showed significantly greater improvements in FMA-UE, MFT and BBT compared to TMT (P<0.05) and CG (P<0.001) groups. Patient experience and satisfaction were more favorable in the 360MT group, with participants reporting higher engagement and motivation.

CONCLUSIONS

360MT appears to be a promising approach for upper extremity rehabilitation in stroke patients, providing better outcomes and higher patient satisfaction. However, further research is needed to confirm these findings and strengthen the evidence base for 360MT in stroke rehabilitation.

CLINICAL REHABILITATION IMPACT

360MT demonstrated notably enhanced upper extremity rehabilitation outcomes as well as better patient satisfaction among chronic stroke patients within six months of onset compared to traditional MT and conventional physical therapy. This novel approach not only fostered functional improvements but also elevated levels of engagement and motivation among participants, suggesting a promising future application in stroke rehabilitation framework.

The effects of respiratory muscle training on respiratory function and functional capacity in patients with early stroke: a meta-analysis

BACKGROUND

Respiratory muscle training is a continuous and standardized training of respiratory muscles, but the evidence of the effects on early stroke patients is not clear. This meta-analysis aimed to investigate the effects of respiratory muscle training on respiratory function and functional capacity in patients with early stroke.

METHODS

PubMed, Embase, PEDro, ScienceDirect, AMED, CINAHL, and China National Knowledge Infrastructure databases were searched from inception to December 8, 2023 for articles about studies that 1) stroke patients with age ≥ 18 years old. Early stroke < 3 months at the time of diagnosis, 2) respiratory muscle training, including inspiratory and expiratory muscle training, 3) the following measurements are the outcomes: respiratory muscle strength, respiratory muscle endurance, pulmonary function testing, dyspnea fatigue score, and functional capacity, 4) randomized controlled trials. Studies that met the inclusion criteria were extracted data and appraised the methodological quality and risk of bias using the Physiotherapy Evidence Database scale and the Cochrane Risk of Bias tool by two independent reviewers. RevMan 5.4 with a random effect model was used for data synthesis and analysis. Mean differences (MD) or standard mean differences (SMD), and 95% confidence interval were calculated (95%CI).

RESULTS

Nine studies met inclusion criteria, recruiting 526 participants (mean age 61.6 years). Respiratory muscle training produced a statistically significant effect on improving maximal inspiratory pressure (MD = 10.93, 95%CI: 8.51-13.36), maximal expiratory pressure (MD = 9.01, 95%CI: 5.34-12.69), forced vital capacity (MD = 0.82, 95%CI: 0.54-1.10), peak expiratory flow (MD = 1.28, 95%CI: 0.94-1.63), forced expiratory volume in 1 s (MD = 1.36, 95%CI: 1.13-1.59), functional capacity (SMD = 0.51, 95%CI: 0.05-0.98) in patients with early stroke. Subgroup analysis showed that inspiratory muscle training combined with expiratory muscle training was beneficial to the recovery of maximal inspiratory pressure (MD = 9.78, 95%CI: 5.96-13.60), maximal expiratory pressure (MD = 11.62, 95%CI: 3.80-19.43), forced vital capacity (MD = 0.87, 95%CI: 0.47-1.27), peak expiratory flow (MD = 1.51, 95%CI: 1.22-1.80), forced expiratory volume in 1 s (MD = 0.76, 95%CI: 0.41-1.11), functional capacity (SMD = 0.61, 95%CI: 0.08-1.13), while inspiratory muscle training could improve maximal inspiratory pressure (MD = 11.60, 95%CI: 8.15-15.05), maximal expiratory pressure (MD = 7.06, 95%CI: 3.50-10.62), forced vital capacity (MD = 0.71, 95%CI: 0.21-1.21), peak expiratory flow (MD = 0.84, 95%CI: 0.37-1.31), forced expiratory volume in 1 s (MD = 0.40, 95%CI: 0.08-0.72).

CONCLUSIONS

This study provides good-quality evidence that respiratory muscle training is effective in improving respiratory muscle strength, pulmonary function, and functional capacity for patients with early stroke. Inspiratory muscle training combined with expiratory muscle training seems to promote functional recovery in patients with early stroke more than inspiratory muscle training alone.

TRIAL REGISTRATION

Prospero registration number: CRD42021291918.

Therapeutic robots for post-stroke rehabilitation

Stroke is a prevalent, severe, and disabling health-care issue on a global scale, inevitably leading to motor and cognitive deficits. It has become one of the most significant challenges in China, resulting in substantial social and economic burdens. In addition to the medication and surgical interventions during the acute phase, rehabilitation treatment plays a crucial role in stroke care. Robotic technology takes distinct advantages over traditional physical therapy, occupational therapy, and speech therapy, and is increasingly gaining popularity in post-stroke rehabilitation. The use of rehabilitation robots not only alleviates the workload of healthcare professionals but also enhances the prognosis for specific stroke patients. This review presents a concise overview of the application of therapeutic robots in post-stroke rehabilitation, with particular emphasis on the recovery of motor and cognitive function.

Three-Dimensional Magnetic Rehabilitation, Robot-Enhanced Hand-Motor Recovery after Subacute Stroke: A Randomized Controlled Trial

We developed an end-effector-type rehabilitation robot that can uses electro- and permanent magnets to generate a three-way magnetic field to assist hand movements and perform rehabilitation therapy. This study aimed to investigate the therapeutic effect of a rehabilitation program using a three-dimensional (3D) magnetic force-based hand rehabilitation robot on the motor function recovery of the paralyzed hands of patients with stroke. This was a double-blind randomized controlled trial in which 36 patients with subacute stroke were assigned to intervention and control groups of 18 patients each. The intervention group received 30 min of rehabilitation therapy per day for a month using a 3D magnetic force-driven hand rehabilitation robot, whereas the control group received 30 min of conventional occupational therapy to restore upper-limb function. The patients underwent three behavioral assessments at three time points: before starting treatment (T0), after 1 month of treatment (T1), and at the follow-up 1-month after treatment completion (T2). The primary outcome measure was the Wolf Motor Function Test (WMFT), and secondary outcome measures included the Fugl-Meyer Assessment of the Upper Limb (FMA_U), Modified Barthel Index (MBI), and European Quality of Life Five Dimensions (EQ-5D) questionnaire. No participant safety issues were reported during the intervention. Analysis using repeated measures analysis of variance showed significant interaction effects between time and group for both the WMFT score (p = 0.012) and time (p = 0.010). In post hoc analysis, the WMFT scores and time improved significantly more in the patients who received robotic rehabilitation at T1 than in the controls (p = 0.018 and p = 0.012). At T2, we also consistently found improvements in both the WMFT scores and times for the intervention group that were superior to those in the control group (p = 0.024 and p = 0.018, respectively). Similar results were observed for FMA_U, MBI, and EQ-5D. Rehabilitation using the 3D hand-rehabilitation robot effectively restored hand function in the patients with subacute stroke, contributing to improvement in daily independence and quality of life.

Centering Patient and Clinician Voices in Developing Tools to Address Pain Related School Impairment: A Phase I Study of a Virtual Reality School Simulation for Children and Adolescents with Chronic Pain

Building on growing evidence supporting virtual reality (VR) interventions for pain management, this study describes the process of developing vReal-School (vRS), a VR-based school simulation for children and adolescents with chronic pain and associated school impairment. Following guidelines for developing user-centered VR interventions, initial phases of intervention development focus on understanding and incorporating patient and clinician perspectives when designing this digital health tool. Phase I entailed focus groups with patients undergoing intensive interdisciplinary pain treatment (IIPT). A total of 19 participants across four focus groups shared their experiences related to dealing with pain at school and provided initial feedback on the concept of a VR-based school simulation. In phase II, we pilot-tested a vRS prototype and collected patient and clinician feedback via mixed method approaches. Phase I results highlight four themes related to pain in school, including physical/environmental challenges and solutions, academic challenges and solutions, peer interaction challenges and solutions, and teacher interaction challenges and solutions. These themes guided the development of our vRS prototype. Nine patients and eleven treating clinicians then engaged with the vRS prototype and provided feedback via semi-structured interviews and validated self-report measures. The results indicate high levels of patient engagement/immersion (mean total score of 17.0 on the Child Presence Measure). Qualitative feedback from both groups identified positive aspects of vRS, including finding the simulation realistic and easy to use and offering ways to address school functioning goals that are not otherwise feasible in the IIPT setting. Areas for improvement included integrating more physical movement as well as increasing the number of scenarios and the level of demands of the tasks available. Both patients and clinicians found vRS to be useful in the IIPT context and relevant to treatment goals. This user input will guide subsequent iterations of intervention development.

Current evidence, clinical applications, and future directions of transcranial magnetic stimulation as a treatment for ischemic stroke

Transcranial magnetic stimulation (TMS) is a non-invasive brain neurostimulation technique that can be used as one of the adjunctive treatment techniques for neurological recovery after stroke. Animal studies have shown that TMS treatment of rats with middle cerebral artery occlusion (MCAO) model reduced cerebral infarct volume and improved neurological dysfunction in model rats. In addition, clinical case reports have also shown that TMS treatment has positive neuroprotective effects in stroke patients, improving a variety of post-stroke neurological deficits such as motor function, swallowing, cognitive function, speech function, central post-stroke pain, spasticity, and other post-stroke sequelae. However, even though numerous studies have shown a neuroprotective effect of TMS in stroke patients, its possible neuroprotective mechanism is not clear. Therefore, in this review, we describe the potential mechanisms of TMS to improve neurological function in terms of neurogenesis, angiogenesis, anti-inflammation, antioxidant, and anti-apoptosis, and provide insight into the current clinical application of TMS in multiple neurological dysfunctions in stroke. Finally, some of the current challenges faced by TMS are summarized and some suggestions for its future research directions are made.

Virtual reality-induced motor function of the upper extremity and brain activation in stroke: study protocol for a randomized controlled trial

Background

The benefits of virtual reality (VR)-based rehabilitation were reported in patients after stroke, but there is insufficient evidence about how VR promotes brain activation in the central nervous system. Hence, we designed this study to explore the effects of VR-based intervention on upper extremity motor function and associated brain activation in stroke patients.

Methods/design

In this single-center, randomized, parallel-group clinical trial with a blinded assessment of outcomes, a total of 78 stroke patients will be assigned randomly to either the VR group or the control group. All stroke patients who have upper extremity motor deficits will be tested with functional magnetic resonance imaging (fMRI), electroencephalography (EEG), and clinical evaluation. Clinical assessment and fMRI will be performed three times on each subject. The primary outcome is the change in performance on the Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE). Secondary outcomes are functional independence measure (FIM), Barthel Index (BI), grip strength, and changes in the blood oxygenation level-dependent (BOLD) effect in the ipsilesional and contralesional primary motor cortex (M1) on the left and right hemispheres assessed with resting-state fMRI (rs-fMRI), task-state fMRI (ts-fMRI), and changes in EEG at the baseline and weeks 4 and 8.

Discussion

This study aims to provide high-quality evidence for the relationship between upper extremity motor function and brain activation in stroke. In addition, this is the first multimodal neuroimaging study that explores the evidence for neuroplasticity and associated upper motor function recovery after VR in stroke patients.

Clinical trial registration

Chinese Clinical Trial Registry, identifier: ChiCTR2200063425.

Virtual Reality-Augmented Physiotherapy for Chronic Pain in Youth: Protocol for a Randomized Controlled Trial Enhanced With a Single-Case Experimental Design

BACKGROUND

Chronic musculoskeletal (MSK) pain is a prominent health concern, resulting in pain-related disability, loss of functioning, and high health care costs. Physiotherapy rehabilitation is a gold-standard treatment for improving functioning in youth with chronic MSK pain. However, increasing physical activity can feel unattainable for many adolescents because of pain-related fear and movement avoidance. Virtual reality (VR) offers an immersive experience that can interrupt the fear-avoidance cycle and improve engagement in physiotherapy. Despite promising initial findings, data are limited and often lack the rigor required to establish VR as an evidence-based treatment for MSK pain.

OBJECTIVE

This trial evaluates physiorehabilitation with VR in adolescents with MSK pain. This protocol outlines the rationale, design, and implementation of a randomized controlled trial enhanced with a single-case experimental design.

METHODS

This study is a 2-group randomized controlled trial assessing the use of physiorehabilitation with VR in adolescents with MSK pain. The authors will collaborate with physical therapists to integrate VR into their standard clinical care. For participants enrolled in standard physiotherapy, there will be no VR integrated into their physical therapy program. Primary outcomes include physical function and engagement in VR. Secondary outcomes include pain-related fear and treatment adherence. Moreover, we will obtain clinician perspectives regarding the feasibility of integrating the intervention into the flow of clinical practice.

RESULTS

The pilot study implementing physiorehabilitation with VR demonstrated that high engagement and use of physiorehabilitation with VR were associated with improvements in pain, fear, avoidance, and function. Coupled with qualitative feedback from patients, families, and clinicians, the pilot study results provide support for this trial to evaluate physiorehabilitation with VR for youth with chronic MSK pain. Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024.

CONCLUSIONS

Significant breakthroughs for treating MSK pain require mechanistically informed innovative approaches. Physiorehabilitation with VR provides exposure to progressive challenges, real-time feedback, and reinforcement for movement and can include activities that are difficult to achieve in the real world. It has the added benefit of sustaining patient motivation and adherence while enabling clinicians to use objective benchmarks to influence progression. These findings will inform the decision of whether to proceed with a hybrid effectiveness-dissemination trial of physiorehabilitation with VR, serving as the basis for potential large-scale implementation of physiorehabilitation with VR.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04636177; https://clinicaltrials.gov/ct2/show/NCT04636177.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40705.

Virtual reality for neurorehabilitation: A bibliometric analysis of knowledge structure and theme trends

Background

As an emerging technology, virtual reality (VR) has been broadly applied in the medical field, especially in neurorehabilitation. The growing application of VR therapy promotes an increasing amount of clinical studies. In this paper, we present a bibliometric analysis of the existing studies to reveal the current research hotspots and guide future research directions.

Methods

Articles and reviews on the related topic were retrieved from the Science Citation Index Expanded of Web of Science Core Collection database. VOSviewer and Citespace software were applied to systematically analyze information about publications, countries, institutions, authors, journals, citations, and keywords from the included studies.

Results

A total of 1,556 papers published between 1995 and 2021 were identified. The annual number of papers increased gradually over the past three decades, with a peak publication year in 2021 (n = 276). Countries and institutions from North America and Western European were playing leading roles in publications and total citations. Current hotspots were focused on the effectiveness of VR therapy in cognitive and upper limb motor rehabilitation. The clusters of keywords contained the four targeted neurological diseases of VR, while the burst keywords represented that the latest studies were directed toward more defined types of VR therapy and greater study design.

Conclusions

Our study offers information regarding to the current hotspots and emerging trends in the VR for rehabilitation field. It could guide future research and application of VR therapy in neurorehabilitation.

Rapid assessment of hand reaching using virtual reality and application in cerebellar stroke

The acquisition of sensory information about the world is a dynamic and interactive experience, yet the majority of sensory research focuses on perception without action and is conducted with participants who are passive observers with very limited control over their environment. This approach allows for highly controlled, repeatable experiments and has led to major advances in our understanding of basic sensory processing. Typical human perceptual experiences, however, are far more complex than conventional action-perception experiments and often involve bi-directional interactions between perception and action. Innovations in virtual reality (VR) technology offer an approach to close this notable disconnect between perceptual experiences and experiments. VR experiments can be conducted with a high level of empirical control while also allowing for movement and agency as well as controlled naturalistic environments. New VR technology also permits tracking of fine hand movements, allowing for seamless empirical integration of perception and action. Here, we used VR to assess how multisensory information and cognitive demands affect hand movements while reaching for virtual targets. First, we manipulated the visibility of the reaching hand to uncouple vision and proprioception in a task measuring accuracy while reaching toward a virtual target (n = 20, healthy young adults). The results, which as expected revealed multisensory facilitation, provided a rapid and a highly sensitive measure of isolated proprioceptive accuracy. In the second experiment, we presented the virtual target only briefly and showed that VR can be used as an efficient and robust measurement of spatial memory (n = 18, healthy young adults). Finally, to assess the feasibility of using VR to study perception and action in populations with physical disabilities, we showed that the results from the visual-proprioceptive task generalize to two patients with recent cerebellar stroke. Overall, we show that VR coupled with hand-tracking offers an efficient and adaptable way to study human perception and action.

Haptic Glove Systems in Combination with Semi-Immersive Virtual Reality for Upper Extremity Motor Rehabilitation after Stroke: A Systematic Review and Meta-Analysis

Background: The effectiveness of the virtual reality (VR) for the upper extremity (UE) motor rehabilitation after stroke has been widely studied. However, the effectiveness of the combination between rehabilitation gloves and semi-immersive VR (SVR) compared to conventional treatment has not yet been studied. Methods: A systematic search was conducted in Pubmed, Web of Science, PEDRo, and Scopus, Cochrane, CINHAAL databases from inception to May 2022. Randomized controlled trials were included if patients were under rehabilitation with haptic gloves combined with SVR intervention focused on the UE rehabilitation in stroke patients. Risk of bias and methodological quality were evaluated with the Physiotherapy Evidence Database (PEDro), and the modified Cochrane library criteria. A random effects model was used for the quantitative assessment of the included studies using the standard mean difference with a 95% confidence interval. Heterogeneity among the included studies was assessed using Cochran’s Q test and the incoherence index (I2). Results: After a first screening, seven studies were included. Significant differences with a 95% confidence interval were obtained in favor of the rehabilitation glove combined with SVR in the short term (SMD—standardized mean differences = 0.38, 95% CI—confidence interval = 0.20; 0.56; Z: 4.24; p =< 0.001). In the long term, only the studies that performed an intervention based in rehabilitation glove combined with SVR with also included rehabilitation were able to maintain the improvements (SMD = 0.71, 95% CI = 0.40; 1.02; Z: 4.48; p =< 0.001). Conclusions: The combined use of rehabilitation haptic gloves and SVR with conventional rehabilitation produces significant improvements with respect to conventional rehabilitation treatment alone in terms of functionality of the UE in stroke patients.

Robotic Table and Serious Games for Integrative Rehabilitation in the Early Poststroke Phase: Two Case Reports

BACKGROUND

BrightArm Compact is a new rehabilitation system for the upper extremities. It provides bimanual training with gradated gravity loading and mediates interactions with cognitively challenging serious games.

OBJECTIVE

The aim of this study is to design and test a robotic rehabilitation table-based virtual rehabilitation system for functional impact of the integrative training in the early poststroke phase.

METHODS

A new robotic rehabilitation table, controllers, and adaptive games were developed. The 2 participants underwent 12 experimental sessions in addition to the standard of care. Standardized measures of upper extremity function (primary outcome), depression, and cognition were administered before and after the intervention. Nonstandardized measures included game variables and subjective evaluations.

RESULTS

The 2 case study participants attained high total arm repetitions per session (504 and 957) and achieved high grasp and finger-extension counts. Training intensity contributed to marked improvements in affected shoulder strength (225% and 100% increase), grasp strength (27% and 16% increase), and pinch strength (31% and 15% increase). The shoulder flexion range increased by 17% and 18% and elbow supination range by 75% and 58%. Improvements in motor function were at or above minimal clinically important difference for the Fugl-Meyer Assessment (11 and 10 points), Chedoke Arm and Hand Activity Inventory (11 and 14 points), and Upper Extremity Functional Index (19 and 23 points). Cognitive and emotive outcomes were mixed. Subjective rating by participants and training therapists were positive (average 4, SD 0.22, on a 5-point Likert scale).

CONCLUSIONS

The design of the robotic rehabilitation table was tested on 2 participants in the early poststroke phase, and results are encouraging for upper extremity functional gains and technology acceptance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04252170; https://clinicaltrials.gov/ct2/show/NCT04252170.

Early-phase dose articulation trials are underutilized for post-stroke motor recovery: A systematic scoping review

BACKGROUND

To enable development of effective interventions, there is a need to complete systematic early-phase dose articulation research. This scoping review aimed to synthesize dose articulation research of behavioral motor interventions for stroke recovery.

METHODS

MEDLINE and EMBASE were systematically searched for dose articulation studies. Preclinical experiments and adult clinical trials were classified based on the discovery pipeline and analyzed to determine which dose dimensions were articulated (time, scheduling or intensity) and how they were investigated (unidimensional vs multidimensional approach). Reporting of dose, safety and efficacy outcomes were summarized. The intervention description, risk of bias, and quality was appraised.

RESULTS

We included 41 studies: 3 of preclinical dose preparation (93 rodents), 2 Phase I dose ranging (21 participants), 9 Phase IIA dose screening (198 participants), and 27 Phase IIB dose finding (1879 participants). All studies adopted a unidimensional approach. Time was the most frequent dimension investigated (53%), followed by intensity (29%), and scheduling (18%). Overall, 95% studies reported an efficacy outcome; however, only 65% reported dose and 45% reported safety. Across studies, 61% were at high risk of bias, and the average percentage reporting of intervention description and quality was 61% and 67%, respectively.

CONCLUSION

This review highlights a need to undertake more high-quality, early-phase studies that systematically articulate intervention doses from a multidimensional perspective in the field of behavioral motor stroke recovery. To address this gap, we need to invest in adapting early phase trial designs, especially Phase I, to support multidimensional dose articulation.

Applications of Healthcare Robots in Combating the COVID-19 Pandemic

Due to the increasing number of COVID-19 cases, there is a remarkable demand for robots, especially in the clinical sector. SARS-CoV-2 mainly propagates due to close human interactions and contaminated surfaces, and hence, maintaining social distancing has become a mandatory preventive measure. This generates the need to treat patients with minimal doctor-patient interaction. Introducing robots in the healthcare sector protects the frontline healthcare workers from getting exposed to the coronavirus as well as decreases the need for medical personnel as robots can partially take over some medical roles. The aim of this paper is to highlight the emerging role of robotic applications in the healthcare sector and allied areas. To this end, a systematic review was conducted regarding the various robots that have been implemented worldwide during the COVID-19 pandemic to attenuate and contain the virus. The results obtained from this study reveal that the implementation of robotics into the healthcare field has a substantial effect in controlling the spread of SARS-CoV-2, as it blocks coronavirus propagation between patients and healthcare workers, along with other advantages such as disinfection or cleaning.

Effects of virtual reality intervention on neural plasticity in stroke rehabilitation: a systematic review

OBJECTIVE

To systematically review and examine the current literature regarding the effects of Virtual Reality (VR)-based rehabilitation on neural plasticity changes in stroke survivors.

DATA SOURCES

Six bioscience and engineering databases were searched, including Medline via Ebsco, Embase, PsycINFO, IEEE Explore, Cumulative Index of Nursing and Allied Health, and Scopus.

STUDY SELECTION

Studies reporting on the pre-post assessment of a VR intervention with neural plasticity measures published between 2000-2021 were included.

DATA EXTRACTION

Two independent reviewers conducted study selection, data extraction and quality assessment. Methodological quality of controlled trials was assessed using the Physiotherapy Evidence Database scale. Risk of bias of pre-post intervention and case studies was evaluated using the National Institutes of Health Quality Assessment Tool.

DATA SYNTHESIS

Twenty-seven studies (Total n=232) were included. Seven randomized controlled trials were rated as good quality while the two clinical controlled trials were moderate. Based on the risk of bias assessment, one pre-post study and one case study were graded as good quality, one pre-post study and one case study were poor, the other 14 studies were all at fair. After the VR intervention, main neurophysiological findings across studies include: (1) improved interhemispheric balance, (2) enhanced cortical connectivity, (3) increased cortical mapping of the affected limb muscles, (4) the improved neural plasticity measures were correlated to the enhanced behavior outcomes, (5) increased activation of regions in frontal cortex and (6) the mirror neuron system may be involved.

CONCLUSIONS

Virtual reality induced changes in neural plasticity for stroke survivors. Positive correlations between the neural plasticity changes and functional recovery elucidates the mechanisms of VR's therapeutic effects in stroke rehabilitation. This review prompts systematic understanding of the neurophysiological mechanisms of VR-based stroke rehabilitation and summarizes the emerging evidence for ongoing innovation of VR systems and application in stroke rehabilitation.

Virtual reality applied to home-visit rehabilitation for hemiplegic shoulder pain in a stroke patient: a case report

Objectives: Virtual reality (VR) has been shown to facilitate rehabilitation at hospitals by distracting patients’ attention from pain and by providing a virtual environment favorable for motivating the patients to continue rehabilitation. However, the application of VR in a home-visit rehabilitation remains to be validated. Here, we report a case in which home-visit rehabilitation using immersive VR was effective for post-stroke hemiplegic shoulder pain.

Case presentation: After treatment, at a general hospital, for the hypertensive hemorrhage in the right brain capsule that resulted in the residual attention deficit disorder and left hemiplegia, a 63-year-old woman was cared for with a home-visit rehabilitation in a rural area. The patient had persistent pain in her left shoulder, which increased during activities of daily living and during rehabilitation, and the pain precluded rehabilitation. A VR relaxation program was delivered to the patient to alleviate pain during rehabilitation. Her shoulder pain was successfully alleviated using VR during training for muscle stretching and passive joint mobilization.

Conclusion: The application of VR to home rehabilitation in rural areas may augment the effectiveness of home rehabilitation by alleviating pain during the procedure and sustaining the motivation for home rehabilitation.

Evidence of neuroplasticity with robotic hand exoskeleton for post-stroke rehabilitation: a randomized controlled trial

Background

A novel electromechanical robotic-exoskeleton was designed in-house for the rehabilitation of wrist joint and Metacarpophalangeal (MCP) joint.

Objective

The objective was to compare the rehabilitation effectiveness (clinical-scales and neurophysiological-measures) of robotic-therapy training sessions with dose-matched conventional therapy in patients with stroke.

Methods

A pilot prospective parallel randomized controlled study at clinical settings was designed for patients with stroke within 2 years of chronicity. Patients were randomly assigned to receive an intervention of 20 sessions of 45 min each, five days a week for four weeks, in Robotic-therapy Group (RG) (n = 12) and conventional upper-limb rehabilitation in Control-Group (CG) (n = 11). We intended to evaluate the effects of a novel exoskeleton based therapy on the functional rehabilitation outcomes of upper-limb and cortical-excitability in patients with stroke as compared to the conventional-rehabilitation. Clinical-scales– Modified Ashworth Scale, Active Range of Motion, Barthel-Index, Brunnstrom-stage and Fugl-Meyer (FM) scale and neurophysiological measures of cortical-excitability (using Transcranial Magnetic Stimulation) –Motor Evoked Potential and Resting Motor threshold, were acquired pre- and post-therapy.

Results

No side effects were noticed in any of the patients. Both RG and CG showed significant (p < 0.05) improvement in all clinical motor-outcomes except Modified Ashworth Scale in CG. RG showed significantly (p < 0.05) higher improvement over CG in Modified Ashworth Scale, Active Range of Motion and Fugl-Meyer scale and FM Wrist-/Hand component. An increase in cortical-excitability in ipsilesional-hemisphere was found to be statistically significant (p < 0.05) in RG over CG, as indexed by a decrease in Resting Motor Threshold and increase in the amplitude of Motor Evoked Potential. No significant changes were shown by the contralesional-hemisphere. Interhemispheric RMT-asymmetry evidenced significant (p < 0.05) changes in RG over CG indicating increased cortical-excitability in ipsilesional-hemisphere along with interhemispheric changes.

Conclusion

Robotic-exoskeleton training showed improvement in motor outcomes and cortical-excitability in patients with stroke. Neurophysiological changes in RG could most likely be a consequence of plastic reorganization and use-dependent plasticity.

Trial registry number: ISRCTN95291802

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00867-7.

Action observation treatment-based exoskeleton (AOT-EXO) for upper extremity after stroke: study protocol for a randomized controlled trial

Background

Stroke produces multiple symptoms, including sensory, motor, cognitive and psychological dysfunctions, among which motor deficit is the most common and is widely recognized as a major contributor to long-term functional disability. Robot-assisted training is effective in promoting upper extremity muscle strength and motor impairment recovery after stroke. Additionally, action observation treatment can enhance the effects of physical and occupational therapy by increasing neural activation. The AOT-EXO trial aims to investigate whether action observation treatment coupled with robot-assisted training could enhance motor circuit activation and improve upper extremity motor outcomes.

Methods

The AOT-EXO trial is a multicentre, prospective, three-group randomized controlled trial (RCT). We will screen and enrol 132 eligible patients in the trial implemented in the Department of Rehabilitation Medicine of Tongji Hospital, Optical Valley Branch of Tongji Hospital and Hubei Province Hospital of Integrated Chinese & Western Medicine in Wuhan, China. Prior to study participation, written informed consent will be obtained from eligible patients in accordance with the Declaration of Helsinki. The enrolled stroke patients will be randomized to three groups: the CT group (conventional therapy); EXO group (exoskeleton therapy) and AOT-EXO group (action observation treatment-based exoskeleton therapy). The patients will undergo blinded assessments at baseline, post-intervention (after 4 weeks) and follow-up (after 12 weeks). The primary outcome will be the Fugl-Meyer Assessment for Upper Extremity (FMA-UE). Secondary outcomes will include the Action Research Arm Test (ARAT), modified Barthel Index (MBI), kinematic metrics assessed by inertial measurement unit (IMU), resting motor threshold (rMT), motor evoked potentials (MEP), functional magnetic resonance imaging (fMRI) and safety outcomes.

Discussion

This trial will provide evidence regarding the feasibility and efficacy of the action observation treatment-based exoskeleton (AOT-EXO) for post-stroke upper extremity rehabilitation and elucidate the potential underlying kinematic and neurological mechanisms.

Trial registration

Chinese Clinical Trial Registry ChiCTR1900026656. Registered on 17 October 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05176-x.

Virtual Rehabilitation of the Paretic Hand and Arm in Persons With Stroke: Translation From Laboratory to Rehabilitation Centers and the Patient's Home

The anatomical and physiological heterogeneity of strokes and persons with stroke, along with the complexity of normal upper extremity movement make the possibility that any single treatment approach will become the definitive solution for all persons with upper extremity hemiparesis due to stroke unlikely. This situation and the non-inferiority level outcomes identified by many studies of virtual rehabilitation are considered by some to indicate that it is time to consider other treatment modalities. Our group, among others, has endeavored to build on the initial positive outcomes in studies of virtual rehabilitation by identifying patient populations, treatment settings and training schedules that will best leverage virtual rehabilitation's strengths. We feel that data generated by our lab and others suggest that (1) persons with stroke may adapt to virtual rehabilitation of hand function differently based on their level of impairment and stage of recovery and (2) that less expensive, more accessible home based equipment seems to be an effective alternative to clinic based treatment that justifies continued optimism and study.

Relative and Absolute Reliability of a Motor Assessment System Using KINECT® Camera

(1) Background: Virtual reality is currently useful in different clinical specialties as a diagnostic and therapeutic tool. In this study, we analyzed the relative and absolute reliability of the motor evaluation with the Kinect camera, a markerless motion system. (2) Methods: Observational study in healthy people, whose inclusion criteria were: healthy people, age 18 to 40 years old without pathologies or injuries in osteoarticular structures or ligamentous muscle and pharmacological treatment with influence on motor skills. Fifty-two subjects were evaluated. (3) Results: The results of the relative reliability were favorable in variables such as the amplitude of passage of the right leg (ICC (Intraclass Correlation Coefficient) = 0.95 ± 0.03), the step width of the left leg (ICC = 0.92 ± 0.04) or balance of the left leg (ICC = 0.90 ± 0.05). Moderate values were found for other variables. The absolute reliability, measured by the coefficient of variation, was favorable in most of the variables. (4) Conclusions: The results reflect a favorable intraclass correlation in the evaluation of the variation and asymmetry of movements of the upper limbs, the balance of both legs, the side step width and the evaluation of the sitting and standing positions. The reliability of the evaluation of the variation of movements and the asymmetry of the lower limbs must be further improved.

Virtual reality interventions to enhance upper limb motor improvement after a stroke: commonly used types of platform and outcomes

Introduction: Virtual Reality (VR) based platforms are useful in enhancing post-stroke sub-optimal upper limb (UL) motor improvement. A variety of options are available from expensive highly customizable platforms to low cost turnkey solutions. Clinical outcomes primarily help assess the effects of VR-based platforms. These outcomes mainly quantify how much improvement has occurred. Very few outcomes characterize the type (i.e. how) of recovery. We categorized the types of VR-based platforms and outcome measures commonly used for post-stroke UL motor improvement.Methods: We reviewed the published literature in English from 2000-2019. Different types of VR-based platforms were grouped into those available commercially and those developed by the various research groups. We initially classified outcomes from the retrieved studies under the appropriate International Classification of Functioning categories. Then, we divided the outcomes as those quantifying the type or extent of improvement.Results: We found a total of 125 studies. Majority of the studies used commercially available platforms. A total of 42 different outcome measures were used. Seventeen different outcomes were used to assess body structure and functions as well as in activity limitations. Eight outcomes assessed the effects of contextual factors and participation restrictions. The Fugl Meyer Assessment, Wolf Motor Function Test and Stroke Impact Scale were most often used across the three categories. Of the 125 studies, 52 used outcomes characterizing the type of recovery. Although a smaller proportion, 24 studies included movement patterns outcomes.Conclusion: A standardized set of outcomes can promote better comparisons between studies using different VR-based platforms for post-stroke UL motor improvement.Implications for RehabilitationA wide variety of commercially available systems are present from expensive customizable systems to low-cost turnkey systems.The Fugl-Meyer Assessment and Wolf Motor Function Test along with the Stroke Impact Scale-Social Participation subscale were used most often across all studies as assessments of body structure and function, activity limitations and participation restriction.It is essential to include movement pattern outcomes addressing whether recovery of compensation occurs with the use of VR-based platforms.

Non-Immersive Virtual Reality for Rehabilitation of the Older People: A Systematic Review into Efficacy and Effectiveness

: Objective: the objective of this review is to analyze the advances in the field of rehabilitation through virtual reality, while taking into account non-immersive systems, as evidence have them shown to be highly accepted by older people, due to the lowest "cibersikness" symptomatology.

DATA SOURCES

a systematic review of the literature was conducted in June 2019. The data were collected from Cochrane, Embase, Scopus, and PubMed databases, analyzing manuscripts and articles of the last 10 years.

STUDY SELECTION

we only included randomized controlled trials written in English aimed to study the use of the virtual reality in rehabilitation. We selected 10 studies, which were characterized by clinical heterogeneity.

DATA EXTRACTION

quality evaluation was performed based on the Physioterapy Evidence Database (PEDro) scale, suggested for evidence based review of stroke rehabilitation. Of 10 studies considered, eight were randomized controlled trials and the PEDro score ranged from four to a maximum of nine.

DATA SYNTHESIS

VR (Virtual Reality) creates artificial environments with the possibility of a patient interaction. This kind of experience leads to the development of cognitive and motor abilities, which usually positively affect the emotional state of the patient, increasing collaboration and compliance. Some recent studies have suggested that rehabilitation treatment interventions might be useful and effective in treating motor and cognitive symptoms in different neurological disorders, including traumatic brain injury, multiple sclerosis, and progressive supranuclear palsy.

CONCLUSIONS

as it is shown by the numerous studies in the field, the application of VR has a positive impact on the rehabilitation of the most predominant geriatric syndromes. The level of realism of the virtual stimuli seems to have a crucial role in the training of cognitive abilities. Future research needs to improve study design by including larger samples, longitudinal designs, long term follow-ups, and different outcome measures, including functional and quality of life indexes, to better evaluate the clinical impact of this promising technology in healthy old subjects and in neurological patients.