Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review

Effects of VR task-oriented training combined with rTMS on balance function and brain plasticity in stroke patients: a randomized controlled trial study protocol

BACKGROUND

Balance dysfunction affects 70% of stroke patients. Emerging neurophysiological approaches, such as virtual reality therapy (VRT) and repetitive transcranial magnetic stimulation (rTMS), have been proven by clinical studies that the balance function of stroke patients can be improved when applied alone, but there are relatively few studies on the combined treatment of balance dysfunction after stroke. This study aimed to evaluate the impact of a 4-week intensive intervention combining VRT and rTMS on both balance function and brain plasticity among stroke patients.

METHODS

This single-blind, randomized controlled trial was conducted at the Rehabilitation Medical Center of the Rehabilitation General Hospital of Ningxia Medical University. A cohort of 136 stroke patients, with durations of 2 to 24 weeks post-stroke, were enrolled in the study. Participants were randomly allocated in a 1:1:1:1 ratio to four groups: the VR group (n = 34), the rTMS group (n = 34), the combined treatment group receiving both VR and rTMS (n = 34), and the control group undergoing traditional balance training (n = 34). All patients underwent a standardized inpatient rehabilitation program over 4 weeks. The VR group received daily 30-min sessions of VR therapy for 20 days. The rTMS group underwent daily sessions of rTMS stimulation for 20 min, targeting the motor imagery region in the affected hemisphere. The combination group received VR therapy after completing their rTMS treatment. The control group received conventional balance training, with each session lasting 30 min. Additionally, all patients received an extra 60 min of standard rehabilitation therapy twice daily. Assessments were conducted at baseline, 2 weeks, and 4 weeks post-treatment, using the Berg Balance Scale (BBS) as the primary measure, and secondary measures including the Timed Up-and-Go Test (TUGT), Fugl-Meyer Assessment-Lower Extremity (FMA-LE), and 6-m walking test (6MWT), as well as assessments for brain-derived neurotrophic factor (BDNF), vascular endothelial growth factor (VGEF), tyrosine receptor kinase (TrκB), motor-evoked potential latency (PL), central motor conduction time (CMCT), and amplitude.

DISCUSSION

The widespread application of VR technology and rTMS in clinical settings is well-established. However, the potential synergistic effects of combining these modalities on balance function and neuroplasticity in stroke patients remain uncertain. Our hypothesis suggests that the integration of VR with rTMS may result in more pronounced improvements in both balance function and neuroplasticity among stroke patients, surpassing the outcomes achievable with VR alone, rTMS alone, or traditional therapy. The possible mechanism is that VR-based training combined with rTMS plays a superimposed effect, promoting better repair of damaged neurons and ultimately improving balance function in stroke patients. The positive results anticipated from this trial could provide objective evidence advocating for the concurrent use of VR and rTMS in clinical interventions.

TRIAL REGISTRATION

The study protocol underwent review and approval by the Medical Research Ethics Committee of the General Hospital of Ningxia Medical University on January 26, 2024 (No. KYLL-2024-0162). Subsequently, it was registered in the Chinese Clinical Trial Registry on March 11, 2024 (registration number: ChiCTR2400081775). Currently, the study is still ongoing.

Feasibility of At-Home Hand Arm Bimanual Intensive Training in Virtual Reality: Case Study

This single-participant case study examines the feasibility of using custom virtual reality (VR) gaming software in the home environment for low-dose Hand Arm Bimanual Intensive Training (HABIT). A 10-year-old with right unilateral cerebral palsy participated in this trial. Fine and gross motor skills as well as personal goals for motor outcomes were assessed before and after the intervention using the Box and Blocks Test, Nine-Hole Peg Test, and Canadian Occupational Performance Measure. Movement intensities collected via the VR hardware accelerometers, VR game scores, and task accuracy were recorded via the HABIT-VR software as indices of motor performance. The child and family were instructed to use the HABIT-VR games twice daily for 30 minutes over a 14-day period and asked to record when they used the system. The child used the system and completed the 14-hour, low-dose HABIT-VR intervention across 22 days. There was no change in Box and Blocks Test and Nine-Hole Peg Test scores before and after the intervention. Canadian Occupational Performance Measure scores increased but did not reach the clinically relevant threshold, due to high scores at baseline. Changes in motor task intensities during the use of VR and mastery of the VR bimanual tasks suggested improved motor efficiency. This case study provides preliminary evidence that HABIT-VR is useful for promoting adherence to HABIT activities and for the maintenance of upper extremity motor skills in the home setting.

Effects of virtual reality on stroke rehabilitation: An umbrella review of systematic reviews

Background and Aims

Virtual reality is an emerging technology in rehabilitation. This umbrella review aimed to identify, critically appraise, and summarize current systematic reviews on the effects of virtual reality on stroke rehabilitation.

Methods

Five biomedical databases, PubMed, Embase, CINAHL, PsycINFO, and Scopus were searched from inception to December 30th, 2023, for systematic reviews with or without meta-analyses published in English. Two reviewers independently conducted abstract screening, full-text selection, and quality assessments. The methodological quality of included studies was evaluated by the Assessing the Methodological Quality of Systematic Reviews 2. Results were qualitatively synthesized according to domains of function to ascertain the effects of virtual reality intervention on functional improvement within stroke rehabilitation.

Results

A total of 78 articles were included; 23 were systematic reviews, and 55 were systematic reviews with meta-analyses. Among them, 30 studies were evaluated as critically low quality, 32 as low, 15 as moderate, and one as good. Outcomes regarding upper extremity motor function, upper extremity activity, participation, functional independence, balance, functional mobility, walking speed, and cognitive function were summarized. While positive effects in favor of virtual reality were revealed by a majority of systematic reviews on these outcomes, evidence supporting the significantly different effects of virtual reality compared to conventional rehabilitation on participation and cognitive function was lacking.

Conclusion

The umbrella review demonstrated promising clinical outcomes regarding the use of virtual reality as an advanced therapeutic approach in stroke rehabilitation to optimize patient care. Future systematic reviews and meta-analyses in this field should adhere to established guidelines to enhance the quality of evidence.

Virtual reality current use, facilitators and barriers to implementation in paediatric physiotherapy: cross-sectional online survey of UK paediatric physiotherapists

BACKGROUND

The literature is scarce about virtual reality (VR) use and its integration into clinical practice. Given the growing interest toward using VR in healthcare in the UK, the aims of this survey were to explore its current use by paediatric physiotherapists in clinical practice in the UK, identify the facilitators and barriers to VR implementation in clinical practice and investigate the factors that will enhance intentions to use it in the future.

METHODS

An online survey using Assessing Determinants of Prospective Take-Up of Virtual Reality (ADOPT-VR2) was distributed to UK paediatric physiotherapists through the Association of Paediatric Chartered Physiotherapists. Descriptive statistics and regression analysis were conducted.

RESULTS

Out of 128 responses, 81 UK-based paediatric physiotherapists completed the survey. The therapists worked in the National Health Service, in the private sector and education. Most of the respondents reported not using VR in clinical practice (n = 75; 93%). Only 7% of respondents reported using VR in clinical practice. Attitudes toward VR, compatibility, and the peer influence constructs of ADOPT-VR2 all significantly predicted the behavioural intention to use VR (R2 = 0.612, p = <0.001).

CONCLUSIONS

This study shows that the current use of VR is limited. The findings from this study suggest that multiple factors need to be reconciled to enhance VR implementation. Specifically, therapists need to be provided with time, appropriate training, and financial and technical support. Stakeholders may also need to consider developing practical manuals to ensure therapists are implementing VR consistently and correctly.

Virtual reality-based supportive care interventions for patients with cancer: an umbrella review of systematic reviews and meta-analyses

PURPOSE

This umbrella review aimed to identify, critically appraise, and synthesize current evidence from systematic reviews and meta-analyses on the applications of virtual reality-based supportive care interventions in cancer.

METHODS

Three bibliographic databases were searched from inception to February 1, 2024. Two independent reviewers screened the titles and abstracts of 421 records and retrieved 26 full-text systematic reviews. Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2) was used for quality assessment. Qualitative syntheses were performed to investigate the effects of virtual reality-based supportive care interventions on quality of life and physical, psychological, cognitive, and functional outcomes. Meta-analysis was performed based on data from the distinct primary studies that were extracted from the included reviews.

RESULTS

This umbrella review included 20 systematic reviews that were published between 2018 and 2023; nine of them conducted meta-analyses. A total of 86 distinct primary studies were identified. According to the AMSTAR-2 assessment, two reviews were evaluated as moderate quality, nine as low, and nine as critically low. Meta-analyses of primary studies revealed significant effects of virtual reality on anxiety (p < 0.001), depression (p < 0.001), and pain (p < 0.001), but not fatigue (p = 0.263). Qualitative syntheses revealed positive effects of virtual reality on physical function, cognitive function, and quality of life. Limited evidence was reported regarding outcomes of balance, gait, mobility, and activities of daily living.

CONCLUSION

Virtual reality has proven to be a safe and feasible approach to deliver supportive care in cancer. Virtual reality can be implemented in various stages and settings of the cancer care continuum to support patients undergoing painful procedures, during or after chemotherapy, and after surgical interventions. Virtual reality can serve as an effective supportive care intervention to manage anxiety, pain, and depression for patients with cancer.

C-Mill Virtual Reality/Augmented Reality Treadmill Training for Reducing Risk of Fall in the Elderly: A Randomized Controlled Trial

Objective: Falling is considered one of the major problems that may affect the elderly, leading to multiple health issues. Walking adaptability to environmental demands is essential for safe walking in the elderly. The aim of this study was to evaluate the efficacy of virtual reality (VR)/augmented reality (AR) treadmill training on balance performance and the risk of falls in the elderly. Materials and Methods: Sixty Saudi elderly individuals of both genders, aged between 60 and 70 years, participated in the study. The participants were categorized into two groups: the experimental and the control groups. Both groups received 1 hour of training: 30 minutes of conventional exercises and 30 minutes of gait training on the C-Mill VR/AR treadmill. The experimental group used the C-Mill treadmill with VR and AR games therapy. The control group had gait training on the C-Mill treadmill without VR and AR. The training for both groups was conducted for 6 successive weeks/three times a week. The changes in the scores of the following variables were recorded at baseline, after 6 weeks of training, and 4 weeks after the completion of training. These variables involved the time needed for completing the Timed Up and Go (TUG) test, overall stability indices of the Fall Risk (FR) test and Limit of Stability (LOS) test evaluated using the Biodex Balance System (BBS), and the time required for completing the LOS test. Results: Both groups demonstrated significant improvement in all measured variables immediately post-training, and this improvement persisted for 4 weeks after completing the training. The experimental group exhibited greater improvement in the recorded values of all measured variables compared with the control group following the training. Conclusions: This study concluded that C-Mill VR/AR treadmill training is effective in improving balance control and reducing the fall risk in the elderly.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A gamified virtual environment intervention for gait rehabilitation in Parkinson's Disease: co-creation and feasibility study

BACKGROUND

Treadmill gait training has been shown to improve gait performance in People with Parkinson's Disease (PwPD), and in combination with Virtual Reality, it can be an effective tool for gait rehabilitation. The addition of gamification elements can create a more stimulating and adherent intervention. However, implementation of new technologies in healthcare can be challenging. This study aimed to develop and evaluate the feasibility of a treadmill rehabilitation program in a Gamified Virtual Reality Environment (GVRE) for PwPD.

METHODS

The GVRE was developed following a user-centered design approach, involving both PwPD and physiotherapists in the development and evaluation of the intervention. The intervention consisted of a walking simulation in three different environments (countryside, city, and park), which had a progressive increase in difficulty. To test its feasibility, three sessions were carried out with four PwPD and four physiotherapists. To assess the usability, the System Usability Scale (SUS), Assistive Technology Usability Questionnaire for people with Neurological diseases (NATU Quest) and Simulator Sickness Questionnaire (SSQ) were used. To assess the intervention's acceptability, feedback and in-game performance was collected from participants.

RESULTS

Results showed the feasibility of the intervention, with a SUS score of 74.82 ± 12.62, and a NATU Quest score of 4.49 ± 0.62, and positive acceptability feedback. Participants showed clear preferences for naturalistic environments, and gamification elements were seen as positive. Difficulty settings worked as intended, but lowered enjoyment of the experience in some cases.

CONCLUSIONS

This intervention was successfully shown as a feasible option for the training of gait under Dual Task conditions for PwPD. It offers a safe and replicable environment in which complex situations can be trained. However, further iterations of the intervention need to be improved in order to guarantee accurate tracking and a more realistic training progression.

TRIAL REGISTRATION NUMBER

NCT05243394-01/20/2022.

Aberrant decision-making as a risk factor for falls in aging

Neuromotor impairments resulting from natural aging and aging-related diseases are often accompanied by a heightened prevalence of falls and fall-related injuries. Conventionally, the study of factors contributing to falls focuses on intrinsic characteristics, such as sensorimotor processing delays and weakness, and extrinsic factors, such as environmental obstacles. However, the impact of these factors only becomes evident in response to people's decisions about how and where they will move in their environment. This decision-making process can be considered a behavioral risk factor, and it influences the extent to which a person engages in activities that place them near the limits of their capacity. While there are readily available tools for assessing intrinsic and extrinsic fall risk, our understanding of how to assess behavioral risk is limited. Measuring behavioral risk requires a systematic assessment of how people make decisions when walking in complex environments and how these decisions relate to their functional capacity. We propose that experimental methods and computational models derived from behavioral economics can stimulate the development of such assessments. Behavioral economics relies on theoretical models and empirical studies to characterize the factors that influence how people make decisions under risky conditions where a given decision can have variable outcomes. Applying a behavioral economic approach to walking can provide insight into how internal assessment of one's fall risk influences the tasks that one is willing to perform. Ultimately, these assessments will allow us to identify people who make choices that increase their likelihood of fall-related injuries.

Effects of Virtual Reality-Assisted and Overground Gait Adaptation Training on Balance and Walking Ability in Stroke Patients: A Randomized Controlled Trial

OBJECTIVE

This study compared the effects of virtual reality-assisted gait adaptation training with the overground gait adaptation training on balance and walking in patients with stroke.

METHODS

Fifty-four eligible patients were enrolled. All patients were randomly divided into a virtual reality and control group, with 27 patients in each group. The virtual reality group received virtual reality-assisted training on the treadmill, whereas the control group received overground training in a physical therapy room. After the intervention, patients were assessed using walking speed, obstacle avoidance ability, Timed Up and Go test, postural stability, and the Barthel Index.

RESULTS

Significant improvements in walking speed, obstacle avoidance ability, Timed Up and Go test, and eye-opening center of pressure speed were observed after the intervention ( P < 0.05). No statistically significant differences were found in eye-closing center of pressure speed, tandem center of pressure speed, single-leg center of pressure speed, and Barthel Index ( P > 0.05).

CONCLUSIONS

Stroke patients may benefit from virtual reality-assisted gait adaptation training in improving walking and static balance function and reducing the risk of falls.

The Effect of Traumatic Brain Injury on Memory

Having a good memory is essential for carrying out daily tasks. People cannot study, plan, remember or navigate life effectively if they are memoryless. People may be at risk when mistakes made in the past will be repeated and lessons regarding danger cannot be learned. In the community, traumatic brain injury (TBI) is common and individuals with TBI frequently have memory problems. It is crucial to study how TBI affects memory to better understand the underlying mechanism and to tailor rehabilitation for patients with a range of pathologies and severity levels. Thus, this paper aimed to review studies related to TBI's effect on memory. This review examined recent studies to learn more regarding and comprehend the connection between TBI and memory, including short-term memory (STM), working memory (WM) and long-term memory (LTM). This will undoubtedly have a big impact on how memory problems that may arise after TBI will be addressed. Virtual reality and other technological advancements have given the medical community a new way to investigate rehabilitative therapy.

Virtual Reality-Induced Modification of Vestibulo-Ocular Reflex Gain in Posturography Tests

Background: The aim of the study was to demonstrate the influence of virtual reality (VR) exposure on postural stability and determine the mechanism of this influence. Methods: Twenty-six male participants aged 21-23 years were included, who underwent postural stability assessment twice before and after a few minute of single VR exposure. The VR projection was a computer-generated simulation of the surrounding scenery. Postural stability was assessed using the Sensory Organization Test (SOT), using Computerized Dynamic Posturography (CDP). Results: The findings indicated that VR exposure affects the visual and vestibular systems. Significant differences (p < 0.05) in results before and after VR exposure were observed in tests on an unstable surface. It was confirmed that VR exposure has a positive influence on postural stability, attributed to an increase in the sensory weight of the vestibular system. Partial evidence suggested that the reduction in vestibulo-ocular reflex (VOR) reinforcement may result in an adaptive shift to the optokinetic reflex (OKR). Conclusions: By modifying the process of environmental perception through artificial sensory simulation, the influence of VR on postural stability has been demonstrated. The validity of this type of research is determined by the effectiveness of VR techniques in the field of vestibular rehabilitation.

Effects of immersive virtual reality training on balance, gait and mobility in older adults: A systematic review and meta-analysis

OBJECTIVE

To examine whether immersive virtual reality (VR) can improve balance, gait, mobility and fear of falling in older people.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, ProQuest Central (Engineering and Computer Science) and reference lists of included articles.

STUDY SELECTION

Randomised controlled trials that administered immersive VR training and assessed balance, gait and mobility outcomes in older adults without neurological disorders (mean age ≥ 65). Primary outcomes were standing balance (e.g. postural sway), multi-item balance scales (e.g. Berg Balance Scale), gait (e.g. gait speed) and mobility (e.g. Timed Up and Go test). Secondary outcomes comprised measures of enjoyment, fear of falling, adherence (e.g. dropout rate), feasibility/usability and adverse effects (e.g. motion sickness).

RESULTS

Meta-analyses showed that immersive VR training significantly improved standing balance (SMD: 0.51, 95% CI: .15, 0.86, p = 0.005, I2 = 28% - 3 studies, n = 79) and performance on the Berg Balance Scale (MD: 2.36, 95% CI: 1.17, 3.56, p=0.0001, I2=0% - 4 studies, n = 190). No significant improvement in gait, mobility or fear of falling was found. Subgroup analyses revealed higher training doses (≥4.5 total hours) and VR interventions using non-head mounted displays were more likely to improve standing balance. No meta-analyses were conducted for enjoyment, adherence, feasibility/usability and adverse events.

CONCLUSIONS

The findings indicate immersive VR has beneficial effects on balance, but not gait, mobility or fear of falling. Further research is required to examine these outcomes in trials that also include quantitative measurements of enjoyment, adherence, clinical feasibility, usability and adverse effects.

Views of Specialist Clinicians and People With Multiple Sclerosis on Upper Limb Impairment and the Potential Role of Virtual Reality in the Rehabilitation of the Upper Limb in Multiple Sclerosis: Focus Group Study

BACKGROUND

Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Using virtual reality (VR) could be a solution to this challenge; however, there is a lack of reporting on the views of people with MS and clinicians on VR-based approaches and recommendations for games for rehabilitation.

OBJECTIVE

This study aims to identify common UL problems and their related current therapeutic approaches for people with MS, and to explore the opinions of people with MS and specialist clinicians on VR and obtain suggestions for the development and design of VR games.

METHODS

Separate focus groups were conducted with people with MS, recruited through the MS Society UK's research network, and clinicians, recruited through the MS Trust Therapists in MS network. A total of 10 people with MS (2 focus groups) and 8 clinicians (5 physiotherapists, 2 occupational therapists, and 1 MS nurse in 2 focus groups) were involved. The focus groups were recorded and transcriptions were analyzed using theme-based content analysis.

RESULTS

People with MS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many people with MS neglected UL exercise and found strategies for adapting to the UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a solution, as it was convenient for people with MS to access and it could provide a more engaging and disguised approach to exercise. There were shared concerns with cybersickness and disengagement with using VR approaches. Both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and people with MS suggesting more abstract activities.

CONCLUSIONS

VR was well received by both people with MS and clinicians for UL rehabilitation. Recommendations were made for the development of VR rehabilitation games which are personalized and customizable for the varying abilities of people with MS.

How Does Postural Control in Patients with Functional Motor Disorders Adapt to Multitasking-Based Immersive Virtual Reality?

BACKGROUND

Motor symptoms in functional motor disorders (FMDs) refer to involuntary, but learned, altered movement patterns associated with aberrant self-focus, sense of agency, and belief/expectations. These conditions commonly lead to impaired posture control, raising the likelihood of falls and disability. Utilizing visual and cognitive tasks to manipulate attentional focus, virtual reality (VR) integrated with posturography is a promising tool for exploring postural control disorders.

OBJECTIVES

To investigate whether postural control can be adapted by manipulating attentional focus in a 3D immersive VR environment.

METHODS

We compared postural parameters in 17 FMDs patients and 19 age-matched healthy controls over a single session under four increasingly more complex and attention-demanding conditions: simple fixation task (1) in the real room and (2) in 3D VR room-like condition; complex fixation task in a 3D VR city-like condition (3) avoiding distractors and (4) counting them. Dual-task effect (DTE) measured the relative change in performance induced by the different attention-demanding conditions on postural parameters.

RESULTS

Patients reduced sway area and mediolateral center of pressure displacement velocity DTE compared to controls (all, P < 0.049), but only under condition 4. They also showed a significant reduction in the sway area DTE under condition 4 compared to condition 3 (P = 0.025).

CONCLUSIONS

This study provides novel preliminary evidence for the value of a 3D immersive VR environment combined with different attention-demanding conditions in adapting postural control in patients with FMDs. As supported by quantitative and objective posturographic measures, our findings may inform interventions to explore FMDs pathophysiology.

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

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

Remotely prescribed and monitored home-based gait-and-balance therapeutic exergaming using augmented reality (AR) glasses: protocol for a clinical feasibility study in people with Parkinson's disease

BACKGROUND

Clinical guidelines for people with Parkinson's disease (pwPD) stress that, complementary to pharmacological treatment, exercise and physiotherapy should be given a central role in disease management. Adhering to regular exercise of the right type, and with high repetition, remains a challenge for pwPD. Exergaming has the potential to increase adherence through play and personalised interventions, both in clinic and at home. Reality DTx® is an augmented-reality (AR) home-based gait-and-balance exergaming intervention specifically designed for pwPD as an extension of supervised physiotherapy. The primary objective of this study is to evaluate the feasibility and potential efficacy of Reality DTx®.

METHODS

Twenty-four pwPD (Hoehn and Yahr stages 2-4) with self-reported gait and/or balance impairments will participate in this study. The study comprises a 6-week waitlist-controlled AR home-based therapeutic gait-and-balance exergaming intervention. Reality DTx® will initially be prescribed remotely for a minimum of 5 days a week for 30 min per day. We will remotely set and adjust the frequency, difficulty, type of games, and/or duration weekly, based on objective and subjective data from the AR glasses and participant, respectively. In addition to the home-based gait-and-balance exergaming intervention, the study comprises three laboratory visits: before the 6-week waitlist period (t0; baseline), before the 6-week intervention period (t1; pre-intervention), and after the 6-week intervention period (t2; post-intervention). The primary study parameters are feasibility (in terms of safety, adherence, and user experience) and potential efficacy for improving gait and balance (using standard clinical gait-and-balance tests and a targeted walking-related fall-risk assessment). Recruitment started in December 2022 and the final post-intervention assessment will be according to planning in July 2023.

CONCLUSIONS

This clinical feasibility trial is the first remotely prescribed and monitored home-based AR gait-and-balance exergaming intervention for pwPD. The results in terms of clinical feasibility (i.e. safety, adherence, and user experience) and potential efficacy (gait, balance, and fall-risk outcomes) form the basis for future randomised controlled studies on the effectiveness of home-based AR gait-and-balance exergaming interventions for pwPD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05605249 . Registered on 4 November 2022.

Therapeutic Quality Affects Physical Fitness Benefits of Home Exercise Interventions in Older Adults: A Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND AND PURPOSE

The international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) tool is a new instrument developed to evaluate the therapeutic quality of exercise interventions. Home-based exercise has been shown to improve physical fitness in older adults, but its effects may be influenced by therapeutic quality. The purpose of this systematic review was to describe the therapeutic quality of home-based exercise interventions for community-dwelling older adults and examine the relationship between therapeutic quality and changes in physical fitness.

METHODS

Six electronic databases and 2 clinical trial registries were searched for randomized controlled trials investigating the effects of home-based exercise on physical fitness in community-dwelling older adults (≥60 years). Therapeutic quality was evaluated using the i-CONTENT tool for items of patient selection, type of exercise, safety, type/timing of outcomes, exercise dose, and adherence. International Consensus on Therapeutic Exercise aNd Training items were used to explain heterogeneity in meta-regression analyses. Risk of bias, certainty of evidence and credibility of analyses were assessed.

RESULTS

Thirty-six trials (n = 6157 participants) were identified. Most studies (≥66.7%) had high or probably high therapeutic quality for i-CONTENT items, except exercise dose (47.2%) and adherence (16.7%). Interventions improved upper- (N = 20 trials; standardized mean difference [SMD] = 0.39; 95% CI, 0.13-0.64; low certainty of evidence) and lower-body strength (N = 28; SMD = 0.42; 95% CI, 0.08-0.77; very low certainty), and aerobic fitness (N = 8; SMD = 0.42; 95% CI, 0.08-0.77; very low certainty). For exercise dose, low- or probably low-quality studies negatively influenced effects on upper- (estimated β = -.48; P = .049; moderate credibility) and lower-body strength (estimated β = -.77; P = .048; moderate credibility). For adherence, low- or probably low-quality studies negatively influenced effects on aerobic fitness (estimated β = -.97; P = .02; low credibility).

CONCLUSIONS

Home-based exercise may improve upper- and lower-body strength, as well as aerobic fitness in older adults. However, the effectiveness of interventions is affected by inadequate dosing of exercise programs and adherence issues. Physical therapists should have the best available evidence to support their clinical decision making, especially when designing and monitoring home programs.

Differences of gait adaptability behavior between young and healthy older adults during a locomotor pointing task in virtual reality

BACKGROUND

Gait adaptability training programs to prevent falls in healthy older adults can be proposed in virtual reality. The development of training programs requires the characterization of the target population.

RESEARCH QUESTION

Before proposing an innovative training program to develop gait adaptability behavior of healthy older adults in fully immersive virtual reality, we had to compare gait adaptability behavior between healthy older adults and young adults in virtual reality.

METHODS

Twenty healthy older adults (with no fall history) and twenty young adults performed a goal-directed locomotion task in a totally secure virtual reality set-up. Gait adaptability behavior was investigated via a set of measures taking into account gait speed, pointing accuracy, and the evolution of the relationship between the participant and the environment through both inter-trial and trial-by-trial analyses. Mann-Whitney tests and linear regressions were performed to determine potential age differences.

RESULTS

The results reveal some common and specific strategies in gait adaptability behavior between healthy older and young adults. In both populations, successive gait adjustments depend on the state of the agent-environment system. However, older adults walked more slowly than young adults (p < .001) with a greater coupling at the end of the target approach (p = .003).

SIGNIFICANCE

In the context of fall prevention in healthy older adults, fully immersive VR appears as a relevant tool to propose relevant gait training programs to improve gait adjustments.

Effects of non-pharmacological interventions on gait and balance of persons with Multiple Sclerosis: A narrative review

BACKGROUND

Multiple Sclerosis (MS) is among the most common reasons for disability in young adults. Mobility impairment, primarily related to gait and balance, is ranked as the preeminent concern among persons with MS (PwMS). Gait and balance dysfunction can directly affect the quality of life and activities of daily life in PwMS, hence the importance of effective treatment strategies. Previous studies have demonstrated the positive effect of various non-pharmacological rehabilitation methods, including physiotherapy and electrical stimulation, on gait and mobility in PwMS. Non-pharmacological methods can be tailored to the individual needs and abilities of each patient, allowing healthcare providers to create personalized training programs. Furthermore, these methods typically result in minimal or no side effects.

PURPOSE

This review provides a comprehensive overview of an array of non-pharmacological treatment approaches aimed at enhancing ambulatory performance in PwMS.

METHODS

We performed a narrative review of the original papers available in PubMed, investigating the effects of different nonmedical approaches on the gait and balance performance of the PwMS. Reviewed treatment approaches include "exercise, physical rehabilitation, dual-task (DT) rehabilitation, robot-assisted rehabilitation, virtual reality-assisted rehabilitation, game training, electrical stimulation devices, auditory stimulation, visual feedback, and shoe insoles".

RESULTS AND CONCLUSIONS

Eighty articles were meticulously reviewed. Our study highlights the positive effects of non-pharmacological interventions on patients' quality of life, reducing disability, fatigue, and muscle spasticity. While some methods, including exercise and physiotherapy, showed substantial promise, further research is needed to evaluate whether visual biofeedback and auditory stimulation are preferable over conventional approaches. Additionally, approaches such as functional electrical stimulation, non-invasive brain stimulation, and shoe insoles demonstrate substantial short-term benefits, prompting further investigation into their long-term effects. Non-pharmacological interventions can serve as a valuable complement to medication-based approaches.

Effects of home-based virtual reality telerehabilitation system in people with multiple sclerosis: A randomized controlled trial

BACKGROUND AND OBJECTIVE

Multiple sclerosis is an inflammatory and neurodegenerative disorder of the central nervous system that can lead to severe motor disability. The aim of this study was to verify the health care effects of an integrated telerehabilitation approach involving dual-domains (motor and cognitive) in people with multiple sclerosis using a virtual reality rehabilitation system compared to a home-based conventional rehabilitative intervention usual care for patient-relevant outcomes (motor, cognitive and participation).

METHODS

This multicentre interventional, randomized controlled trial included 70 participants with multiple sclerosis, 35 in the telerehabilitation group (30 sessions of home-based virtual reality rehabilitation system training, five sessions for week each lasting 45 min) and 35 in the usual care group (30 sessions of conventional treatment, five sessions for week). Participants completed the assessment of motor, cognitive and participation outcomes at baseline and after 6 weeks of treatment.

RESULTS

In total, 63.3% of the telerehabilitation group exhibited improvement in the physical domain of the quality of life (p = 0.045). The telerehabilitation group showed greater improvement than the usual care group in Mini-BESTest domains of balance (p = 0.014), postural control (p = 0.024), and dynamic walking (p = 0.020) at post-treatment. Higher adherence was registered for telerehabilitation compared with usual care (86.67% vs. 80.0%).

DISCUSSION

This study provides evidence that people with multiple sclerosis can benefit from telerehabilitation treatment in the physical domain of the quality of life and motor symptoms. Moreover, considering the persistent COVID-19 emergency, telerehabilitation can represent an effective telemedicine solution for safely delivering effective rehabilitation care to people with multiple sclerosis.

TRIAL REGISTRATION NUMBER AND TRIAL REGISTER

This trial was registered at ClinicalTrials.gov (NCT03444454).

Does an outdoor virtual environment projected in a head-mounted display affect balance in healthy young adults?

BACKGROUND

Virtual reality head-mounted display (VR-HMD) is increasingly used for balance evaluation and rehabilitation. However, more studies must be conducted on virtual environments (VE) effects. This study aimed to assess the impact of an outdoor VE projected in a high-quality VR-HMD and of the VR-HMD mass on postural stability, postural control and leaning.

METHODS

This study involved ten healthy young men who performed five 30-s stabilometric trials. Four experimental conditions were randomly performed: eyes open (EO) or eyes closed (EC), with (VR) or without (No VR) VR-HMD. Postural stability (antero-posterior (AP) and medio-lateral (ML) ranges of the center of pressure (CoP), 90% confidence ellipse area), postural control (CoP velocity (global, AP and ML)) and standard deviation of the CoP mean position), and postural leaning (AP/ML CoP mean position) were assessed. The comparisons between EO VR and EO No VR were used to analyze the VE effects and comparisons between EC VR and EC No VR for the VR-HMD mass effects.

RESULTS

Spatiotemporal parameters that characterised postural stability and postural control, except ML velocity (p > 0.05), were significantly influenced by the simulated VE with higher values in EO VR than EO No VR (p < 0.05), but not by the VR-HMD mass. The mean position of the CoP showed no significant differences between conditions.

SIGNIFICANCE

Postural stability and postural control modification due to the VE used in this study revealed that this VE could be interesting for VR-HMD rehabilitation and assessment. VR-HMD is not a factor to be considered for stabilometric analysis.

Progress in neurorehabilitation research and the support by the National Natural Science Foundation of China from 2010 to 2022

The National Natural Science Foundation of China is one of the major funding agencies for neurorehabilitation research in China. This study reviews the frontier directions and achievements in the field of neurorehabilitation in China and worldwide. We used data from the Web of Science Core Collection (WoSCC) database to analyze the publications and data provided by the National Natural Science Foundation of China to analyze funding information. In addition, the prospects for neurorehabilitation research in China are discussed. From 2010 to 2022, a total of 74,220 publications in neurorehabilitation were identified, with there being an overall upward tendency. During this period, the National Natural Science Foundation of China has funded 476 research projects with a total funding of 192.38 million RMB to support neurorehabilitation research in China. With the support of the National Natural Science Foundation of China, China has made some achievements in neurorehabilitation research. Research related to neurorehabilitation is believed to be making steady and significant progress in China.

Use of Virtual Reality in Patients with Acquired Brain Injury: A Systematic Review

BACKGROUND AND OBJECTIVES

ABI is found in all societies as the most severe, disabling neurological disorder. A cognitive rehabilitation program is essential for the clinical recovery of these patients, improving functional outcomes and quality of life. Modern technologies such as virtual reality (VR) offer several advantages over traditional therapies, including the ability to engage people in simulated performance of functional tasks. This review will examine the studies in which virtual reality has been used as an aid, technique, or intervention in patients with acquired brain injury.

MATERIALS AND METHODS

Studies were identified from an online search of PubMed, Cochrane Library, and Web of Science databases.

RESULTS

We found that TBI patients responded positively to VR treatment depending on the damaged or impaired cognitive and motor functions they acquired. It is now a tool that is available in the rehabilitation of these patients and supports the recovery of various motor and cognitive functions.

CONCLUSIONS

This review has shown that VR is an intervention technique that increasingly exists in clinical rehabilitation practice for ABI patients. The device uses advanced technologies that can cause general changes in cognitive, motor, and psychological aspects and create a simulated environment that can partially restore these functions and behaviors, as well as the behaviors of everyday life.

Virtual Reality in Clinical Nursing Practice Over the Past 10 Years: Umbrella Review of Meta-Analyses

Background

Virtual reality (VR) has shown promising levels of effectiveness in nursing education, pain management, and rehabilitation. However, meta-analyses have discussed the effects of VR usage in nursing unilaterally and inconsistently, and the evidence base is diffuse and varied.

Objective

We aimed to synthesize the combined evidence from meta-analyses that assessed the effects of nurses using VR technology on nursing education or patient health outcomes.

Methods

We conducted an umbrella review by searching for meta-analyses about VR intervention in clinical nursing practice on Web of Science, Embase, Cochrane, and PubMed, and in reference lists. Eligible studies were published in English between December 1, 2012, and September 20, 2023. Meta-analyses of ≤2 intervention studies and meta-analyses without 95% CI or heterogeneity data were excluded. Characteristic indicators, population information, VR intervention information, and 95% CIs were extracted. A descriptive analysis of research results was conducted to discern relationships between VR interventions and outcomes. I2 and P values were used to evaluate publication bias. AMSTAR (A Measurement Tool to Assess Systematic Reviews) 2 and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) checklist were used to appraise literature quality.

Results

In total, 768 records were identified; 74 meta-analyses were included for review. The most reported VR study conditions were neuronursing (25/74, 34%), pediatric nursing (13/74, 18%), surgical and wound care (11/74, 15%), oncological nursing (11/74, 15%), and older adult nursing (10/74, 14%). Further, 30% (22/74) of meta-analyses reported publication bias, and 15% (11/74) and 8% (6/74) were rated as "high" based on AMSTAR 2 and the GRADE checklist, respectively. The main outcome indicators among all included meta-analyses were pain (37/214, 17.3%), anxiety (36/214, 16.8%), cognitive function (17/214, 7.9%), balance (16/214, 7.5%), depression (16/214, 7.5%), motor function (12/214, 5.6%), and participation in life (12/214, 5.6%). VR treatment for cognition, pain, anxiety, and depression was effective (all P values were <.05), while the utility of VR for improving motor function, balance, memory, and attention was controversial. Adverse effects included nausea, vomiting, and dizziness (incidence: range 4.76%-50%). The most common VR platforms were Pico VR glasses, head-mounted displays, the Nintendo Wii, and the Xbox Kinect. VR intervention duration ranged from 2 weeks to 12 months (typically ≥4 wk). VR session length and frequency ranged from 5 to 100 minutes and from 1 to 10 times per week, respectively.

Conclusions

VR in nursing has positive effects-relieving patients' pain, anxiety, and depression and improving cognitive function-despite the included studies' limited quality. However, applying VR in nursing to improve patients' motor function, balance, memory, and attention remains controversial. Nursing researchers need to further explore the effects and standard operation protocols of VR in clinical practice, and more high-quality research on VR in nursing is needed.

An Internet- and Kinect-Based Multiple Sclerosis Fitness Intervention Training With Pilates Exercises: Development and Usability Study

BACKGROUND

Balance impairments are common in people with multiple sclerosis (MS), with reduced ability to maintain position and delayed responses to postural adjustments. Pilates is a popular alternative method for balance training that may reduce the rapid worsening of symptoms and the increased risk of secondary conditions (eg, depression) that are frequently associated with physical inactivity.

OBJECTIVE

In this paper, we aimed to describe the design, development, and usability testing of MS Fitness Intervention Training (MS-FIT), a Kinect-based tool implementing Pilates exercises customized for MS.

METHODS

MS-FIT has been developed using a user-centered design approach (design, prototype, user feedback, and analysis) to gain the target user's perspective. A team composed of 1 physical therapist, 2 game programmers, and 1 game designer developed the first version of MS-FIT that integrated the knowledge and experience of the team with MS literature findings related to Pilates exercises and balance interventions based on exergames. MS-FIT, developed by using the Unity 3D (Unity Technologies) game engine software with Kinect Sensor V2 for Windows, implements exercises for breathing, posture, and balance. Feedback from an Italian panel of experts in MS rehabilitation (neurologists, physiatrists, physical therapists, 1 statistician, and 1 bioengineer) and people with MS was collected to customize the tool for use in MS. The context of MS-FIT is traveling around the world to visit some of the most important cities to learn the aspects of their culture through pictures and stories. At each stay of the travel, the avatar of a Pilates teacher shows the user the exercises to be performed. Overall, 9 people with MS (n=4, 44% women; mean age 42.89, SD 11.97 years; mean disease duration 10.19, SD 9.18 years; Expanded Disability Status Scale score 3.17, SD 0.75) were involved in 3 outpatient user test sessions of 30 minutes; MS-FIT's usability was assessed through an ad hoc questionnaire (maximum value=5; higher the score, higher the usability) evaluating easiness to use, playability, enjoyment, satisfaction, and acceptance.

RESULTS

A user-centered design approach was used to develop an accessible and challenging tool for balance training. All people with MS (9/9, 100%) completed the user test sessions and answered the ad hoc questionnaire. The average score on each item ranged from 3.78 (SD 0.67) to 4.33 (SD 1.00), which indicated a high usability level. The feedback and suggestions provided by 64% (9/14) of people with MS and 36% (5/14) of therapists involved in the user test were implemented to refine the first prototype to release MS-FIT 2.0.

CONCLUSIONS

The participants reported that MS-FIT was a usable tool. It is a promising system for enhancing the motivation and engagement of people with MS in performing exercise with the aim of improving their physical status.

A comparative study on the overlapping effects of clinically applicable therapeutic interventions in patients with central nervous system damage

This study was conducted to investigate the effects of anti-gravity treadmill (AGT) training, which provides visual feedback and Biorescue training on proprioception, muscle strength, balance, and gait, in stroke patients. A total of 45 people diagnosed with post-stroke were included as study subjects; they were randomized to an AGT training group provided with visual feedback (Group A), a Biorescue training group provided with visual feedback (Group B), and an AGT/Biorescue group that subsequently received AGT training and Biorescue training (Group C). A muscle strength-measuring device was used to evaluate muscle strength. Timed Up and Go and Bug Balance Scale assessment sheets were used to evaluate balance ability. Dartfish software was used to evaluate gait ability. The results of the study showed that Groups A and C had a significant increase in muscle strength compared with Group B; in terms of balance and gait abilities, Group C showed a significant increase in balance ability and gait speed and a significant change in knee joint angle compared with Groups A and B. In conclusion, this study suggests that including a method that applies multiple therapeutic interventions is desirable in the rehabilitation of stroke patients to improve their independence.

Effectiveness of virtual reality-based balance and gait in older adults with fear of movement: A systematic review and meta-analysis

OBJECTIVE

To summarize the current evidence from randomized controlled trials (RCTs) regarding the effectiveness of Virtual Reality (VR) training and functional mobility in older adults with fear of movement. TYPE: Systematic review and meta-analysis of randomized clinical trials.

METHODOLOGY

An electronic search was performed using PubMed, Embase, Medline, SPORTDiscus, Scopus, and CINAHL. A data search from January 2015 to December 2022 and a manual electronic literature search were conducted to identify published RCTs. The effectiveness of VR-based balance training for balance and gait was evaluated in older adults with a fear of movement, which was measured by the Timed Up and Go (TUG) test and the Falls Efficacy Scale (FES). Three reviewers independently performed the study selection, and the quality assessment of the included studies was performed using the Physiotherapy Evidence Database (PEDro) scale. The reporting was based on the new Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines.

SYNTHESIS

The search product produced 345 results, from which 23 full text articles were studied. Seven RCTs of good methodological quality, including 265 participants, were included in the review. Overall, the studies reported that VR had a significant improvement on the TUG (Cohen's d = -0.91 [-1.38; -0.44], p = 0.001), while the FES was not significantly different (Cohen's d = -0.54 [-1.80; 0.71] p = 0.40). The average for PEDro scores (6.14) was good, and the risk of bias revealed that more than one-third of the studies correctly described the random sequence generation and allocation concealment procedures.

CONCLUSION

VR-based training is effective on balance or gait training based on the TUG; however, there were mixed results to improve FES scores following VR intervention. These inconsistent results might be limited due to variations in the studies, including heterogeneous training paradigms, sensitive outcome measures, small sample sizes, and short intervention durations, which limit the validity of our findings. Future investigations should compare different VR protocols to help establish better guidelines for clinicians.

Comparison between the effect of immersive virtual reality training versus conventional rehabilitation on limb loading and functional outcomes in patients after anterior cruciate ligament reconstruction: A prospective randomized controlled trial

Purpose

Anterior cruciate ligament injury (ACL) commonly occurs during sporting events. It causes pain, instability and reduction in range of movement of the knee which results in altered balance, reduced strength as well as loading to the involved knee. The challenge to get the patient back to competitive sports level much depends on the rehabilitation process. Post ACLR rehabilitation is challenging due to the long rehabilitation time as well as boring repetitive exercises. The aim of this study is to compare between the effectiveness of using immersive virtual reality (PlayStation VR) in addition to the conventional rehabilitation as an aid in rehabilitation of patients after ACLR in terms of objective functional assessment and pain and subjective knee function scoring.

Methods

This randomised controlled trial was undertaken in a tertiary hospital in Malaysia from July 2019 until July 2020. Thirty patients were randomised into a group undergoing purely conventional rehabilitation (Group 1) and a group undergoing both conventional rehabilitation and immersive virtual reality assisted rehabilitation (Group 2). The immersive virtual reality assisted rehabilitation was started at 3 months post operatively for 3 months duration. Limb loading, balance, range of motion, functional hop tests of the knee, pain and subjective scoring of the knee with the International Knee Documentation Committee (IKDC) Scores were measured preoperatively and at 6 months.

Results

There were significant differences in terms of improvement of pain scores (p = 0.012) as well as IKDC Scores (p = 0.024) in Group 2 as compared to Group 1. However, there were no significant differences with regards to limb loading, balance, range of motion and functional hop tests of the knee (p > 0.05). No adverse events were observed during the study period.

Conclusion

Immersive virtual reality can be used as an adjunct in rehabilitation of patients after ACL reconstruction in terms of improving their pain as well as their subjective knee evaluation. Large randomised control trial is recommended to further investigate the efficacy.

Designing environments that contribute to a reduction in the progression of Parkinson's disease; a literature review

Parkinson's Disease (PD), a prevalent neurological disorder, causes physical difficulties like stiffness and impaired walking and affects patients' emotional well-being. Regular exercise and exposure to enriched environments are crucial to managing these symptoms. This review aims to extract evidence from studies regarding built environments' impact on reducing the progression of PD. Keywords from 2005 to 2022 were used in five databases, including PubMed, Clarivate Web of Science, UGA Library, and Google Scholar. Many studies emphasized physiotherapy and training for physical enhancement, often utilizing virtual games and smart devices. Others highlighted the advantages of non-slip flooring and accessible outdoor spaces, with some based on universal design principles. Few studies considered the emotional impact of built environments, showing a considerable gap in the studies simultaneously evaluating psychological and physical perspectives of Parkinson-friendly environments. There needs to be more consistency when considering these aspects of planning. Our findings suggest future research modeling enriched environments and tracking their impact on patients via Virtual Reality to find a comprehensive guideline for the most effective PD management environments.

The effectiveness of virtual reality games in improving cognition, mobility, and emotion in elderly post-stroke patients: a systematic review and meta-analysis

This review is aimed to assess the effectiveness of virtual reality (VR) games on cognition, mobility, and emotion in elderly stroke patients. We selected relevant articles from eight databases from 2011 to 2022 and extracted articles on cognitive ability (general cognition, mini-mental state examination (MMSE), Montreal cognitive assessment (MoCA) et al.), mobility (modified Barthel index (MBI), Fugl-Meyer assessment (FMA), Berg balance scale (BBS), functional independence measure motor (FIM MOT)), and emotion (depression/anxiety). Twenty-nine studies including 1311 participants were included in the analysis. In the results, virtual reality games were more effective in improving overall cognitive function in stroke patients compared to conventional therapies. In addition, the intervention group in the MMSE (SMD = 0.6, 95%CI = 0.26-0.95, P = 0.0007), MoCA (MD = 1.97, 95%CI = 1.3-2.64, P < 0.00001), and attention test (MD = 0.25, 95% CI = 0.01-0.49, P < 0.00001) scores were also higher. In terms of physical function, MBI (SMD = 0.61, 95%CI = 0.14-1.08, P = 0.01), FMA (SMD = 0.47, 95%CI = 0.02-0.93, P = 0.04), BBS (SMD = 0.78, 95%CI = 0.42-1.15, P < 0.0001), and FIM MOT (MD = 5.87, 95%CI = 2.57-9.17, P = 0.0005) indicators showed better results. It is also observed that virtual reality games can effectively relieve depression and improve mental health in stroke patients. Sports game training, especially with VR equipment, had a positive impact on improving the cognitive performance, mobility, and emotional state of stroke patients compared to a control group. Although the improvement in cognitive ability is relatively low, the effect of improving physical activity and depression is obvious.

Interventions to Improve Standing Balance in Individuals With Incomplete Spinal Cord Injury: A Systematic Review and Meta-Analysis

Background

Incomplete spinal cord injury (iSCI) often results in impaired balance leading to functional impairments. Recovery of standing balance ability is an important aim of rehabilitative programs. However, limited information is available on effective balance training protocols for individuals with iSCI.

Objectives

To assess the methodological quality and effectiveness of various rehabilitation interventions for improving standing balance in individuals with iSCI.

Methods

A systematic search was performed in SCOPUS, PEDro, PubMed, and Web of Science from inception until March 2021. Two independent reviewers screened articles for inclusion, extracted data, and evaluated methodological quality of the trials. PEDro Scale was used to assess the quality of randomized controlled trials (RCT) and crossover studies while pre-post trials were assessed using the modified Downs and Black tool. A meta-analysis was performed to quantitatively describe the results. The random effects model was applied to present the pooled effect.

Results

Ten RCTs with a total of 222 participants and 15 pre-post trials with 967 participants were analyzed. The mean PEDro score and modified Downs and Black score was 7/10 and 6/9, respectively. The pooled standardized mean difference (SMD) for controlled and uncontrolled trials of body weight-supported training (BWST) interventions was -0.26 (95% CI, -0.70 to 0.18; p = .25) and 0.46 (95% CI, 0.33 to 0.59; p < .001), respectively. The pooled effect size of -0.98 (95% CI, -1.93 to -0.03; p = .04) indicated significant improvements in balance after a combination of BWST and stimulation. Pre-post studies analyzing the effect of virtual reality (VR) training interventions on Berg Balance Scale (BBS) scores in individuals with iSCI reported a mean difference (MD) of 4.22 (95% CI, 1.78 to 6.66; p = .0007). Small effect sizes were seen in pre-post studies of VR+stimulation and aerobic exercise training interventions indicating no significant improvements after training on standing balance measures.

Conclusion

This study demonstrated weak evidence to support the use of BWST interventions for overground training for balance rehabilitation in individuals with iSCI. A combination of BWST with stimulation however showed promising results. There is a need for further RCTs in this field to generalize findings. Virtual reality-based balance training has shown significant improvement in standing balance post iSCI. However, these results are based on single group pre-post trials and lack appropriately powered RCTs involving a larger sample size to support this intervention. Given the importance of balance control underpinning all aspects of daily activities, there is a need for further well-designed and appropriately powered RCTs to evaluate specific features of training interventions to improve standing balance function in iSCI.

Virtual Reality-Based Rehabilitation to Restore Motor Function in People With Amputation: A Systematic Literature Review

ABSTRACT

Virtual reality is an emerging technology with accumulating research and clinical evidence in the field of physical rehabilitation. This study aimed to systematically identify and examine the effects of virtual reality on motor function outcomes in patients with amputation to inform clinical decision making on amputation rehabilitation and inform further research endeavors. Five databases were searched, including PubMed, CINAHL, PsycINFO, Embase, and Scopus. After screening for 1052 records, 10 clinical studies were included in this review: four randomized controlled trials, three pre-post single-arm studies, and three case studies; all studies had fair to good methodological quality. Seven studies were for lower extremity amputation, and three were for upper extremity amputation. Results reveal the positive effects of virtual reality on improving motor function in prosthesis training, including balance, gait, and upper extremity outcomes. Participants also report enjoyment during virtual reality intervention as measured by subjective experience. However, it is unclear whether virtual reality can induce better therapeutic outcomes than conventional rehabilitation, given the limited number of controlled studies and conflicting results reported in the included studies. More properly designed randomized controlled trials with adequately powered sample sizes are warranted to elucidate the benefits of virtual reality-based rehabilitation in the amputation population.

Virtual reality augments effectiveness of treadmill walking training in patients with walking and balance impairments: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To systematically summarize and examine current evidence regarding the combination of virtual reality and treadmill training in patients with walking and balance impairments.

DATA SOURCES

English language randomized controlled trials, participants with walking and balance impairments, intervention group used virtual reality and treadmill, control group only used treadmill with the same training frequency and number of sessions. Six bioscience and engineering databases were searched.

METHODS

Two independent reviewers conducted study selection, data extraction, and quality assessment. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Sixteen randomized controlled trials including 829 participants were identified. Compared to treadmill-only training, virtual reality augmented treadmill training induced significantly faster walking (p < 0.001; standardized mean difference (SMD) = 0.55, 95%CI: 0.30 to 0.81), longer step length (p < 0.001; SMD = 0.74, 95%CI: 0.42 to 1.06), narrower step width (p = 0.03; SMD = -0.52, 95%CI: -0.97 to -0.06), longer single leg stance period (p = 0.003; SMD = 0.77, 95%CI: 0.27 to 1.27), better functional mobility (p = 0.003; SMD = -0.44, 95%CI: - 0.74 to -0.15), improved balance function (p = 0.04; SMD = 0.24, 95%CI: 0.01 to 0.47), and enhanced balance confidence (p = 0.03; SMD = 0.73, 95%CI: 0.08 to 1.37). Walking endurance did not differ significantly between groups (p = 0.21; SMD = 0.13, 95%CI: -0.07 to 0.34).

CONCLUSIONS

Virtual reality augmented treadmill walking training enhances outcomes compared to treadmill-only training in patients with walking and balance impairments. The results of this review support the clinical significance of combining virtual reality with treadmill training with level 1A empirical evidence.

Virtual reality-based therapy improves balance and reduces fear of falling in patients with multiple sclerosis. a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aims to conduct a meta-analysis to assess the effect of virtual reality-based therapy (VRBT) on balance dimensions and fear of falling in patients with multiple sclerosis (PwMS). Secondarily, to determine the most recommendable dose of VRBT to improve balance.

METHODS

PubMed Medline, Web of Science, Scopus, CINAHL and PEDro were screened, without publication date restrictions, until September 30th, 2021. Randomized controlled trials (RCTs) comparing the effectiveness of VRBT against other interventions in PwMS were included. Functional and dynamic balance, confidence of balance, postural control in posturography, fear of falling and gait speed were the variables assessed. A meta-analysis was performed by pooling the Cohen's standardized mean difference (SMD) with 95% confidence interval (95% CI) using Comprehensive Meta-Analysis 3.0.

RESULTS

Nineteen RCTs, reporting 858 PwMS, were included. Our findings reported that VRBT is effective in improving functional balance (SMD = 0.8; 95%CI 0.47 to 1.14; p < 0.001); dynamic balance (SMD = - 0.3; 95%CI - 0.48 to - 0.11; p = 0.002); postural control with posturography (SMD = - 0.54; 95%CI - 0.99 to - 0.1; p = 0.017); confidence of balance (SMD = 0.43; 95%CI 0.15 to 0.71; p = 0.003); and in reducing fear of falling (SMD = - 1.04; 95%CI - 2 to - 0.07; p = 0.035); but not on gait speed (SMD = - 0.11; 95%CI: - 0.35 to 0.14; p = 0.4). Besides, the most adequate dose of VRBT to achieve the greatest improvement in functional balance was at least 40 sessions, five sessions per week and 40-45 min per sessions; and for dynamic balance, it would be between 8 and 19 weeks, twice a week and 20-30 min per session.

CONCLUSION

VRBT may have a short-term beneficial role in improving balance and reducing fear of falling in PwMS.

Effects of gait training on structural brain changes in Parkinson's disease

BACKGROUND

Gait training may lead to functional brain changes in Parkinson's disease (PD); however, there is a lack of studies investigating structural brain changes after gait training in PD.

OBJECTIVE

To investigate structural brain changes induced by 4 weeks of gait training in individuals with PD.

METHODS

Diffusion tensor imaging and structural T1 images were acquired in PD group before and after robot-assisted gait training or treadmill training, and in healthy control group. Tract-based spatial statistics and tensor-based morphometry were conducted to analyze the data. The outcome of gait training was assessed by gait speed and dual-task interference of cognitive or physical tests of the 10-meter walking test representing gait automaticity. The associations between structural brain changes and these outcomes were investigated using correlation analysis.

RESULTS

A total of 31 individuals with PD (68.5±8.7 years, the Hoehn & Yahr stage of 2.5 or 3) and 28 healthy controls (66.6±8.8 years) participated in this study. Compared to the controls, PD group at baseline showed a significant increased fractional anisotropy (FA) in the right forceps minor and bilateral brainstem and reduced radial diffusivity (RD) in the right superior longitudinal fasciculus, as well as the expanded structural volumes in the several brain areas. After gait training, FA increased in the left internal capsule and it decreased in the left cerebellar Crus I, while the structural volume did not change. The increased FA in the left internal capsule positively correlated with the baseline gait speed and negatively correlated with gait speed improvement; moreover, the decreased FA in the left cerebellum Crus I negatively correlated with the baseline gait speed during the cognitive task.

CONCLUSIONS

Gait training induces white matter changes in the brain of individuals with PD, which suggests the improvement of brain structural pathology to mitigate the impact of neurodegenerative consequences.

Effects of exergaming on cognition, lower limb functional coordination, and stepping time in people with multiple sclerosis: a randomized controlled trial

PURPOSE

To compare the effects of exergaming versus conventional exercises on cognition, lower-limb functional coordination, and stepping time in people with multiple sclerosis (PwMS).

METHODS

Thirty-six PwMS were randomly assigned to either intervention (n = 18) or control (n = 18) group and received 18 training sessions during six weeks. The intervention group performed exergames that required multidirectional timed-stepping, weight-shifting, and walking while the control group performed conventional matched exercises. Trail making test (TMT part A, B; TMT-A, TMT-B, TMT B-A), six-spot step test (SSST), and choice stepping reaction time (CSRT-including reaction time (RT), movement time (MVT), and total response time (TRT)) were assessed pre- and post-intervention (short-term), and after three-month follow-up (mid-term).

RESULTS

The intervention group showed faster TMT-B (p = 0.003) and TMT B-A (p = 0.002) at post-intervention and faster SSST at both post-intervention (p = 0.002) and follow-up (p = 0.04). The CSRT components showed no between-group differences at post-intervention; however, at follow-up, the intervention group had lower TRT (p = 0.046) and MVT (p = 0.015). TMT-A and RT had no significant between-group differences.

CONCLUSIONS

In short-term, exergames led to more improvements in complex attention, executive function, and lower-limb functional coordination comparing to the matched conventional exercises. In mid-term, exergaming was more effective for improving stepping time and lower-limb functional coordination. However, the two approaches did not show any superiority over each other for improving simple attention and RT.Implications for rehabilitationWhen designed properly, exergames have great potential to improve attention and executive function of people with multiple sclerosis (PwMS), at least in the short-term.Exergames seem like an appropriate option for improving lower limb coordination and decreasing choice stepping response time among PwMS in the mid-term.Exergames do not have superiority in improving the choice stepping reaction time compared to their matched conventional treatment.

Virtual reality-based interventions for the rehabilitation of vestibular and balance impairments post-concussion: a scoping review

BACKGROUND

Concussions and mild traumatic brain injuries are the most common causes of physical and cognitive disability worldwide. Concussion can result in post-injury vestibular and balance impairments that can present up to five years post initial concussion event, ultimately affecting many daily and functional activities. While current clinical treatment aims to reduce symptoms, the developing use of technology in everyday life has seen the emergence of virtual reality. Current literature has failed to identify substantial evidence regarding the use of virtual reality in rehabilitation. The primary aim of this scoping review is to identify, synthesise, and assess the quality of studies reporting on the effectiveness of virtual reality for the rehabilitation of vestibular and balance impairments post-concussion. Additionally, this review aims to summarise the volume of scientific literature and identify the knowledge gaps in current research pertaining to this topic.

METHODS

A scoping review of six databases (PubMed, Embase, CINAHL, ProQuest, SportDiscus, Scopus) and a grey literature (Google Scholar) was conducted using three key concepts (virtual reality, vestibular symptoms, and post-concussion). Data was charted from studies and outcomes were categorised into one of three categories: (1) balance; (2) gait; or (3) functional outcome measures. Critical appraisal of each study was conducted using the Joanna Briggs Institute checklists. A critical appraisal of each outcome measure was also completed utilising a modified GRADE appraisal tool to summarise the quality of evidence. Effectiveness was assessed using calculations of change in performance and change per exposure time.

RESULTS

Three randomised controlled trials, three quasi-experimental studies, three case studies, and one retrospective cohort study were ultimately included, using a thorough eligibility criteria. All studies were inclusive of different virtual reality interventions. The ten studies had a 10-year range and identified 19 different outcome measures.

CONCLUSION

The findings from this review suggests that virtual reality is an effective tool for the rehabilitation of vestibular and balance impairments post-concussion. Current literature shows sufficient but low level of evidence, and more research is necessary to develop a quantitative standard and to better understand appropriate dosage of virtual reality intervention.

Can Virtual Reality-Assisted Therapy Offer Additional Benefits to Patients With Vestibular Disorders Compared With Conventional Vestibular Physical Therapy? A Meta-analysis

OBJECTIVE

To determine whether virtual reality-assisted therapy (VRAT) significantly improves the treatment of peripheral or central vestibular disorders when compared with conventional vestibular physical therapy (CVPT) alone. Indicators of vestibular symptoms are used to determine this.

DATA SOURCES

Two reviewers independently searched PubMed, EMBASE, ClinicalTrials.gov, Web of Science, and the Cochrane Collaboration database from January 2010 to January 2022 for studies reporting on VRAT in vestibular disorders.

STUDY SELECTION

Randomized controlled trials (RCTs) were included that mainly focused on the following measures: the Dizziness Handicap Inventory (DHI), Simulator Sickness Questionnaire, visual analog scale, and balance measures such as the Activities-specific Balance Confidence Scale (ABC), timed Up and Go test, sensory organization test, and center of pressure. The primary outcome was assessment of symptomatic changes before and after VRAT.

DATA EXTRACTION

Two authors independently conducted the literature search and selection. After screening, meta-analysis was performed on the RCTs using RevMan 5.3 software.

DATA SYNTHESIS

The results showed that VRAT produced significantly greater improvement than CVPT alone in scores of DHI-Total (standardized mean difference [SMD]: -7.09, 95% confidence interval [CI]: [-12.17, -2.00], P=.006), DHI-Functional (SMD=-3.66, 95% CI: [-6.34, -0.98], P=.007), DHI-Physical (SMD=-3.14, 95% CI: [-5.46, -0.83], P=.008), and DHI-Emotional (SMD=-3.10, 95% CI: [-5.13, -1.08], P=.003). ABC scores did not show improvement (SMD: 0.58, 95% CI: [-3.69, 4.85], P=.79). Subgroup analysis showed that DHI-Total between-group differences were insignificant for central vestibular disorders (SMD=-1.47, 95% CI: [-8.71, -5.78], P=.69), although peripheral disorders showed significant improvements (SMD=-9.58, 95% CI: [-13.92, -5.25], P<.0001). However, the included studies showed high heterogeneity (I²>75%).

CONCLUSIONS

VRAT may offer additional benefits for rehabilitation from vestibular diseases, especially peripheral disorders, when compared with CVPT alone. However, because of high heterogeneity and limited data, additional studies with a larger sample size and more sensitive and specific measurements are required to conclusively determine the evidence-based utility of virtual reality.

Impact of Virtual Reality Cognitive and Motor Exercises on Brain Health

Innovative technologies of the 21st century have an extremely significant impact on all activities of modern humans. Among them, virtual reality (VR) offers great opportunities for scientific research and public health. The results of research to date both demonstrate the beneficial effects of using virtual worlds, and indicate undesirable effects on bodily functions. This review presents interesting recent findings related to training/exercise in virtual environments and its impact on cognitive and motor functions. It also highlights the importance of VR as an effective tool for assessing and diagnosing these functions both in research and modern medical practice. The findings point to the enormous future potential of these rapidly developing innovative technologies. Of particular importance are applications of virtual reality in basic and clinical neuroscience.

Balancing new technology: Virtual reality for balance measurement case report

RATIONALE

Falling and the inability to maintain balance are the second leading cause of unintentional injury deaths globally. There are a number of chronic and acute conditions characterized by balance difficulties, including neurological diseases, and sport injuries. Therefore, methods to monitor and quantify balance are critical for clinical decision-making regarding risk management and balance rehabilitation. New advances in virtual reality (VR) technology has identified VR as a novel therapeutic platform. VRSway is a VR application that uses sensors attached to a virtual reality headset, and handheld remote controllers for measurement and analysis of postural stability by measuring changes in spatial location relative to the center of mass and calculates various postural stability indexes. This case report evaluates balance measures in 2 healthy participants with no previous history of balance disorders using the VRSway software application and compares to output generated by the current gold standard of balance measurement, force platform technology.

CASE PRESENTATION

The primary objective of this case study was to validate the VRSway stability score for evaluation of balance. Here, we present posturography measures of the VRSway in comparison with force plate readouts in 2 healthy participants. Body Sway measurements were recorded simultaneously in both the force plate and VRSway systems. Data calculated by proprietary software is highly correlative to the data generated by force plates for each of the following measurements for participant-1 and participant-2, respectively: Sway index (r 1 = 0.985, P < .001; r 2 = 0.970, P < .001), total displacement (r 1 = 0.982, P < .001; r 2 = 0.935, P < .001), center of pressure mean velocity (r 1 = 0.982, P < .001; r 2 = 0.935, P < .001), ellipse radius 1 (r 1 = 0.979, P < .001; r 2 = 0.965, P < .001), ellipse radius 2 (r 1 = 0.982, P < .001; r 2 = 0.969, P < .001), and ellipse area (r 1 = 0.983, P < .001; r 2 = 0.969, P < .001).

CONCLUSIONS

Data from this case study suggest that VRSway measurements are highly correlated with output from force plate technology posing that VRSway is a novel approach to evaluate balance measures with VR. More research is required to understand possible uses of VR-based use for balance measurement in a larger and more diverse cohort.

Effects of virtual reality on physical, cognitive, and psychological outcomes in cancer rehabilitation: a systematic review and meta-analysis

PURPOSE

To systematically examine and summarize the current evidence regarding the effects of virtual reality (VR) on physical, cognitive, and psychological outcomes in cancer rehabilitation.

METHODS

Six bioscience and engineering databases were searched. Two independent reviewers screened the titles and abstracts of 2397 records and retrieved 25 full-text articles. Inclusion criteria included patients with a current or previous diagnosis of cancer; VR was used as an intervention for physical, cognitive, or psychological impairments and functional limitations; and clinical trials with at least two arms and with both pre- and post-intervention assessments. Reviewers assessed methodological quality using the Physiotherapy Evidence Database scale.

RESULTS

Seventeen studies including 799 patients with cancer were identified. Within-group pooled analysis indicated that patients demonstrated significant improvement in pain (P < 0.001), fatigue (P < 0.001), anxiety (P < 0.001), upper extremity function (P < 0.001), and quality of life (P = 0.008) after VR intervention. Between-group pooled analysis indicated significant improvements with VR in pain (P = 0.004), anxiety (P < 0.001), and upper extremity function (P < 0.001) compared with the control. Three studies reported the positive effects of VR on cognition.

CONCLUSIONS

VR demonstrates promising effects in physical, cognitive, and psychological aspects of patients with cancer. VR can be incorporated into a comprehensive cancer rehabilitation program to alleviate impairments and functional limitations.

Metaverse in Healthcare Integrated with Explainable AI and Blockchain: Enabling Immersiveness, Ensuring Trust, and Providing Patient Data Security

Digitization and automation have always had an immense impact on healthcare. It embraces every new and advanced technology. Recently the world has witnessed the prominence of the metaverse which is an emerging technology in digital space. The metaverse has huge potential to provide a plethora of health services seamlessly to patients and medical professionals with an immersive experience. This paper proposes the amalgamation of artificial intelligence and blockchain in the metaverse to provide better, faster, and more secure healthcare facilities in digital space with a realistic experience. Our proposed architecture can be summarized as follows. It consists of three environments, namely the doctor's environment, the patient's environment, and the metaverse environment. The doctors and patients interact in a metaverse environment assisted by blockchain technology which ensures the safety, security, and privacy of data. The metaverse environment is the main part of our proposed architecture. The doctors, patients, and nurses enter this environment by registering on the blockchain and they are represented by avatars in the metaverse environment. All the consultation activities between the doctor and the patient will be recorded and the data, i.e., images, speech, text, videos, clinical data, etc., will be gathered, transferred, and stored on the blockchain. These data are used for disease prediction and diagnosis by explainable artificial intelligence (XAI) models. The GradCAM and LIME approaches of XAI provide logical reasoning for the prediction of diseases and ensure trust, explainability, interpretability, and transparency regarding the diagnosis and prediction of diseases. Blockchain technology provides data security for patients while enabling transparency, traceability, and immutability regarding their data. These features of blockchain ensure trust among the patients regarding their data. Consequently, this proposed architecture ensures transparency and trust regarding both the diagnosis of diseases and the data security of the patient. We also explored the building block technologies of the metaverse. Furthermore, we also investigated the advantages and challenges of a metaverse in healthcare.

Virtual Reality for Motor and Cognitive Rehabilitation

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

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

BACKGROUND

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

METHODS

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

OBJECTIVE

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

RESULTS

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

CONCLUSIONS

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

Use of virtual reality for targeted physical rehabilitation: Case report on managing functional motor disorder

Virtual reality (VR) technology has seen increasing use in physical rehabilitation and in the management of acute and chronic pain. Functional movement disorders (FMDs) are a source of disability with no known association to neurologic pathology, and patients are generally offered multidisciplinary treatment approaches to improve functional movement. However, patients who are not compliant with rehabilitation may have persistent FMD and long-term disability. Given VR's use in physical rehabilitation, it may serve as a useful adjunct for the management of FMD. Utilizing an application called MovementTM to create a playlist of targeted applications for the restoration of motor function and balance, this case study presents the application of VR as a tool to engage patients in physical therapy for the management of FMD. The VR games were selected to encourage movement while customization of levels within the games facilitated achievement of physical therapy goals. Physical rehabilitation aided by VR, when used in collaboration with a multidisciplinary care team, may be used to facilitate recovery from FMD.

Immersion Therapy with Head-Mounted Display for Rehabilitation of the Upper Limb after Stroke-Review

Immersive virtual therapy technology is a new method that uses head-mounted displays for rehabilitation purposes. It offers a realistic experience that puts the user in a virtual reality. This new type of therapy is used in the rehabilitation of stroke patients. Many patients after this disease have complications related to the upper extremities that limit independence in their everyday life, which affects the functioning of society. Conventional neurological rehabilitation can be supplemented by the use of immersive virtual therapy. The system allows patients with upper limb dysfunction to perform a motor and task-oriented training in virtual reality that is individually tailored to their performance. The complete immersion therapy itself is researched and evaluated by medical teams to determine the suitability for rehabilitation of the upper limb after a stroke. The purpose of this article is to provide an overview of the latest research (2019-2022) on immersive virtual reality with head-mounted displays using in rehabilitation of the upper extremities of stroke patients.

The effect of six week virtual reality training on the improvement of functional balance in women with type-I osteoporosis: A preliminary study

Purpose

This preliminary study aimed to investigate the effects of exergames in a virtual reality environment to improve functional balance during goal-directed functional tasks in postmenopausal women with osteoporosis.

Methods

Twelve volunteer postmenopausal women with osteoporosis were randomly assigned to virtual reality (VRT, n = 6) and conventional multimodal (CMT, n = 6) training groups. The exercise was performed for 6 weeks, 3 days weekly, and 18 sessions. Using a force platform, functional balance assessments were made through four dynamic tasks, including performance-based limits of stability (LOS), curve tracking (CT), sit-to-stand (STS), and turning before and after 18 sessions of treatment. Each task's time-dependent center of pressure (COP) variables was separately calculated via Kistler-Mars software.

Results

The COP variables of LOS and CT tasks were significantly improved after 6 weeks of CMT and VRT (P ≤ 0.05). In the VRT group, the rising index (P < 0.00), COP sway velocity in STS, and Turn sway were significantly reduced (P < 0.05). Following the VRT, the mean difference of forwarding maximum COP excursion increased (P = 0.03), and errors in CT (P = 0.03) significantly decreased.

Conclusion

The VRT and CMT improved the COP sway parameters during weight-shifting tasks. The VRT was more effective than CMT in increasing the ability to control weight-shifting and dynamic functional tasks in postmenopausal women with osteoporosis. This approach in training has suitable potential to provide convenient error feedback learning.

Effects of Non-Immersive Virtual Reality and Video Games on Walking Speed in Parkinson Disease: A Systematic Review and Meta-Analysis

People with Parkinson disease suffer from a loss of dopaminergic neurons, which are involved in walking speed. Currently, virtual reality (VR) has emerged as a useful tool for the rehabilitation of people with neurological diseases, optimizing results in balance and gait. This review aimed to evaluate the effectiveness of VR or video games (through face-to-face sessions and not telerehabilitation) in improving walking speed and other spatio-temporal parameters of gait, balance, and quality of life in patients with Parkinson disease. A bibliographic search was carried out in the MEDLINE, Web of Science, Scopus, and PEDro databases. This systematic review adhered to the PRISMA guideline statement and was registered in PROSPERO (CRD42020180836). From a total of 119 records, 5 studies met the inclusion criteria for qualitative analysis, of which 3 contributed to the meta-analysis; inconclusive findings were found on gait speed, balance, and quality of life after the use of non-immersive VR systems face-to-face. A greater number of studies are necessary, with a greater number of participants, to differentiate between those VR specific systems (specifically designed for rehabilitation) from commercial video games, including immersive systems, and obtain more conclusive evidence. Furthermore, it would be interesting to compare the administration of this treatment in person versus its administration via telerehabilitation, which will help plan treatment programs.

Virtual reality gaming in rehabilitation after stroke - user experiences and perceptions

PURPOSE

The present study explored participants' experiences with and perceptions of using fully immersive head-mounted virtual reality (VR) gaming as rehabilitation after stroke.

METHODS

Four men and three women (median age 64 years) with chronic stroke and varying motor impairment (mild to severe) were interviewed after 10 weeks of VR training on the commercial HTC Vive system, focusing on the upper extremities. Inductive qualitative thematic analysis was performed.

RESULTS

The analysis revealed three main themes: playing the game, benefits and effects, and personalizing the game. Playing the game encompasses both the feeling of being immersed in the game and descriptions of the gaming being motivating and fun. Benefits and effects describe the participants' expectations of potential benefits, the importance of getting feed-back, and the impact in daily life. Personalizing the game includes finding the right game and level, and the participants' need for support to achieve full use of the training.

CONCLUSIONS

Participants with chronic stroke described the fully immersive VR gaming intervention as a fun and motivating way to improve their functioning in everyday life. Qualitative studies are needed to explore how people with stroke perceive VR gaming when it is implemented in real clinical environments.Clinical implicationsVR gaming was perceived as a positive and motivating rehabilitation after stroke.Getting feedback and perceiving benefits are essential parts of VR rehabilitation.Commercial fully immersive VR-games might be an option for stroke rehabilitation when the game can be personalized and support is available.