Effects of community-based virtual reality treadmill training on balance ability in patients with chronic stroke

Wii Fit-Based Biofeedback Rehabilitation Among Post-Stroke Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

BACKGROUND

Stroke is one of the most widespread reasons for acquired adult disability. Recent experimental studies have reported the beneficial influence of Wii Fit-based feedback on improving overall balance and gait for stroke survivors.

METHODS

We conducted a systematic review of the literature using the following keywords to retrieve the data: feedback, biofeedback, stroke, visual, auditory, tactile, virtual reality, videogame rehabilitation, Nintendo Wii stroke, videogame stroke, exergame stroke, Nintendo Wii rehabilitation, balance, and gait. A review and meta-analysis of RCTs regarding Wii Fit-based rehabilitation accompanied by conventional therapy effects on Berg Balance Scale (BBS), Timed Up and Go (TUG), functional reach test, and gait (speed) in stroke survivors was conducted.

OBJECTIVE

To determine the impacts of Wii Fit-based feedback combined with traditional therapy on balance and gait in stroke survivors.

RESULTS

22 studies were included. The meta-analysis results revealed statistically significant improvements in functional ambulation measured using TUG (p < 0.0001), balance measured using BBS (p = 0.0001), and functional reach test (p = 0.01), but not in gait speed (p = 0.32) following Wii Fit-based feedback. Regarding the types of feedback, significant differences were found in BBS scores when mixed visual and auditory feedback was used.

CONCLUSION

Wii Fit-based feedback has desired effects on improving balance in stroke patients, making it a suitable adjunct to physical therapy.

Saponin of Aralia taibaiensis promotes angiogenesis through VEGF/VEGFR2 signaling pathway in cerebral ischemic mice

ETHNOPHARMACOLOGICAL RELEVANCE

Aralia taibaiensis is known for its ability to promote blood circulation and dispel blood stasis, activate meridians and remove arthralgia. The saponins of Aralia taibaiensis (sAT) are the main active components that are often used to treat cardiovascular and cerebrovascular diseases. However, it has not been reported whether sAT can improve ischemic stroke (IS) by promoting angiogenesis.

AIM OF THE STUDY

In this study, we investigated the potential of sAT to promote post-ischemic angiogenesis in mice and determined the underlying mechanism through in vitro experiments.

METHODS

To establish the middle cerebral artery occlusion (MCAO) mice model in vivo. First of all, we examined the neurological function, brain infarct volume, and degree of brain swelling in MCAO mice. We also observed pathological changes in brain tissue, ultrastructural changes in blood vessels and neurons, and the degree of vascular neovascularization. Additionally, we established the oxygen-glucose deprivation/reoxygenation (OGD/R) -human umbilical vein endothelial cells (HUVECs) model in vitro to detect the survival, proliferation, migration and tube formation of OGD/R HUVECs. Finally, we verified the regulatory mechanism of Src and PLCγ1 siRNA on sAT promoting angiogenesis by cell transfection technique.

RESULTS

In the cerebral ischemia-reperfusion mice, sAT distinctly improved the cerebral infarct volume, brain swelling degree, neurological dysfunction, and brain histopathological morphology due to cerebral ischemia/reperfusion injury. It also increased the double positive expression of BrdU and CD31 in brain tissue, promoted the release of VEGF and NO and decreased the release of NSE and LDH. In the OGD/R HUVECs, sAT significantly improved cell survival, proliferation, migration and tube formation, promoted the release of VEGF and NO, and increased the expression of VEGF, VEGFR2, PLCγ1, ERK1/2, Src and eNOS. Surprisingly, the effect of sAT on angiogenesis was inhibited by Src siRNA and PLCγ1 siRNA in OGD/R HUVECs.

CONCLUSION

The results proved that sAT promotes angiogenesis in cerebral ischemia-reperfusion mice and its mechanism is to regulate VEGF/VEGFR2 and then regulate Src/eNOS and PLCγ1/ERK1/2.

A VR-based Treadmill Training System for Post-stroke Gait Rehabilitation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023;2023:1-4. [PMID: 38082773 DOI: 10.1109/embc40787.2023.10340568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Virtual reality (VR) has the potential to enhance rehabilitation by creating simulated multiple training environments, thereby maximizing the implementation of motor learning principles. However, previous use of VR-based treadmill training to improve post-stroke gait function is limited by high cost and a lack of adherence to post-stroke gait rehabilitation principles in system design. This paper describes the development of a gait rehabilitation system that integrates treadmill gait training with VR technology to create a virtual rehabilitation setting with gait training tasks and real-time performance feedback. The proposed system targets post-stroke patients and integrates low-cost sensor and rehabilitation principles to allow remote training and maximize training efficacy.Clinical Relevance-This system is developed with an emphasis on rehabilitation and motor learning principles.

The effect of telerehabilitation on balance in stroke patients: is it more effective than the traditional rehabilitation model? A meta-analysis of randomized controlled trials published during the COVID-19 pandemic

Objective

Telerehabilitation and telemedicine have gradually gained popularity. In 2019, the outbreak of COVID-19 started in Wuhan and then spread across the world. To date, most countries have opted to coexist with the virus. However, patients, especially those who have suffered a stroke, should take measures to avoid being infected with any disease as much as possible since any infectious disease can lead to adverse events for them. Telerehabilitation can be beneficial to stroke patients as they are less likely to be infected by the virus. In recent years, several studies on telerehabilitation have been conducted globally. This meta-analysis aimed to investigate the effects of telerehabilitation on the balance ability of stroke patients, compare the efficacy of conventional rehabilitation with telerehabilitation, explore the characteristics of telerehabilitation and conventional rehabilitation, and provide recommendations for rehabilitation programs in the context of the global pandemic.

Methods

We searched Pubmed, Embase, the Web of Science, and The Cochrane Library databases from 1 January 2020 to 31 December 2022 for randomized controlled trials published in English that evaluated the improvement of balance function in stroke patients after telerehabilitation and compared the differences between telerehabilitation (TR) and conventional rehabilitation (CR). The random-effects model was utilized to calculate mean differences (MDs) with 95% confidence intervals (CIs) to estimate intervention effects. Statistical heterogeneity was assessed according to the I² values. The risk of bias was measured using the Cochrane risk-of-bias assessment tool.

Results

We included nine studies in the system evaluation, all of which were included in the pooled analysis. All outcomes in the experimental and control groups improved over time. The comparison between groups concluded that people who received the telerehabilitation intervention had a significant improvement in the Berg Balance Scale (MD = 2.80; 95% CI 0.61, 4.98, P < 0.05, I2 = 51.90%) and the Fugl-Meyer Assessment (MD = 8.12; 95% CI 6.35, 9.88, P < 0.05, I2 = 0) compared to controls. The Timed Up and Go test (MD = -4.59; 95% CI -5.93, -.25, P < 0.05, I² = 0) and Tinetti Performance-Oriented Mobility Assessment-Balance (MD = 2.50; 95% CI 0.39, 4.61, P < 0.05) scored better in the control group than in the experimental group. There were no significant differences in other outcomes between the two groups.

Conclusion

Studies on changes in medical conditions during the COVID-19 pandemic also demonstrated that, for stroke patients, telerehabilitation achieves similar effects as the conventional rehabilitation model and can act as a continuation of the conventional rehabilitation model. Owing to the different equipment and intervention programs of telerehabilitation, its curative effect on the static balance and reactive balance of stroke patients may be different. Currently, telerehabilitation may be more conducive to the rehabilitation of patients' static balance abilities, while conventional rehabilitation is more effective for the rehabilitation of patients' reactive balance. Therefore, further studies are needed for investigating the difference in efficacy between varied devices and telerehabilitation programs. Further research is needed on static and reactive balance. In addition, such research should have a large body of literature and a large sample size to support more definitive findings based on the context of the COVID-19 pandemic.

Systematic review registration

CRD42023389456.

Effect of Physiotherapy Treatment with Immersive Virtual Reality in Subjects with Stroke: A Protocol for a Randomized Controlled Trial

BACKGROUND

Many stroke survivors suffer from sensorimotor deficits, especially balance impairments. The purpose of this trial is to investigate whether the designed Immersive Virtual Reality training program is better in the short term (15 sessions) and in the medium term (30 sessions) than physiotherapy training with Bayouk, Boucher and Leroux exercises, with respect to static balance in sitting and standing, dynamic balance and quality of life in patients with balance impairment in stroke survivors.

METHODS

This study is a randomized controlled trial with two treatment arms and evaluators blinded, and a functionality treatment group in combination with specific balance exercise training according to Bayouk, Boucher and Leroux (control group) or a balanced treatment using Immersive VR. The primary outcome will be static, Dynamic balance and gait measured by Bestest Assessment Score (BESTest), Berg Scale (BBS), Pass Scale (PASS) and Time Up and Go test (TUG). The secondary outcome will be the stroke-associated quality of life using the Stroke Quality of Life Scale (ECVI-38).

CONCLUSIONS

The results of this study may add new insights into how to address balance using Immersive Virtual Reality after a stroke. If the new training approach proves effective, the results may provide insight into how to design more comprehensive protocols in the future for people with balance impairments after stroke.

Immersive Virtual Reality in Post-Stroke Rehabilitation: A Systematic Review

In recent years, next to conventional rehabilitation's techniques, new technologies have been applied in stroke rehabilitation. In this context, fully immersive virtual reality (FIVR) has showed interesting results thanks to the level of immersion of the subject in the illusional world, with the feeling of being a real part of the virtual environment. This study aims to investigate the efficacy of FIVR in stroke rehabilitation. PubMed, Web of Science and Scopus were screened up to November 2022 to identify eligible randomized controlled trials (RCTs). Out of 4623, we included 12 RCTs involving post-acute and chronic stroke survivors, with a total of 350 patients (234 men and 115 women; mean age 58.36 years). High heterogeneity of the outcomes considered, the results showed that FIVR provides additional benefits, in comparison with standard rehabilitation. In particular, results showed an improvement in upper limb dexterity, gait performance and dynamic balance, influencing patient independence. Therefore, FIVR represents an adaptable, multi-faceted rehabilitation tool that can be considered in post-stroke rehabilitation, improving the compliance of the patients to the treatment and increasing the level of functioning and quality of life of stroke survivors.

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.

Effect of Treadmill Training with Visual Biofeedback on Selected Gait Parameters in Subacute Hemiparetic Stroke Patients

BACKGROUND

Functional limitations after a stroke are unique to each person and often include impaired independent mobility. A reduction in existing gait deficits after a stroke is often one of the main goals of rehabilitation. Gait re-education after stroke is a complex process, which consists of the effects of many therapeutic interventions.

OBJECTIVE

The study aimed to analyze the effects of using a treadmill with visual feedback in gait re-education in the sub-acute stroke period and assess the impact of biofeedback treadmill training on selected gait parameters, improving static balance and reducing the need for orthopedic aids.

METHODS

The study included 92 patients (F: 45, M: 47) aged 63 ± 12 years, with post-ischemic sub-acute (within six months onset) stroke hemiparesis, treated at a neurological rehabilitation ward. All patients participated in a specific rehabilitation program, and in addition, patients in the study group (n = 62) have a further 10 min of treadmill training with visual feedback. Patients in the control group (n = 30) participated in additional conventional gait training under the direct supervision of a physiotherapist. The evaluation of static balance was assessed with the Romberg Test. A Biodex Gait Trainer 3 treadmill with biofeedback function was used to evaluate selected gait parameters (walking speed, step length, % limb loading, and traveled distance). The use of an orthopedic aid (walker or a crutch) was noted.

RESULTS

After four weeks of rehabilitation, step length, walking speed, traveled distance, and static balance were significantly improved for the study and control group (p < 0.05). Treadmill gait training yielded significantly better results than a conventional rehabilitation program. Only the study group observed a corrected walking base (p < 0.001). All participants showed a reduction in the use of walking aids (p = 0.006). There was no asymmetry in the % of limb loading for either group prior to or following rehabilitation.

CONCLUSIONS

The treadmill with visual biofeedback as conventional gait training has resulted in a significant improvement in parameters such as step length, walking speed, static balance, and a reduction in the use of locomotion aids. However, the achieved improvement in gait parameters is still not in line with the physiological norm.

Impact of physical activity on postural stability and coordination in children with posterior fossa tumor: randomized control phase III trial

Background

Posterior fossa tumor is a type of brain tumor that is located at the borders of both the brain stem and cerebellum. The cerebellum is the brain region in charge of balance and coordination. Pediatric patients diagnosed with posterior fossa tumor have been reported to fall frequently.

Objectives

The aim of this study is to investigate the effectiveness of balance and coordination training in these children.

Methods

This randomized control clinical trial (ClinicalTrials.gov Identifier: NCT04528316) was carried out between September 2020 and April 2021 at Children’s Cancer Hospital-57357. The inclusion criteria were patients with posterior fossa tumor in maintenance phase and, age between 5 and 12 years. The exclusion criteria were patients who had a genetic disorder or suffer from mental retardation, a chronic lung disease, severe cardiomyopathy, or a neuromuscular disease that does not relate to tumor. The study participants were randomly assigned into three groups: Group I/Control group: they received Pilates core stability exercises program, Group II/Postural stability group: they received the same program plus HUMAC balance program, and Group III/Coordination group: they received the same program plus coordination exercises of BOT-2. The semi-parametric proportional odds model was used to compare follow-up scores of the Postural stability group vs Control, and Coordination group vs Control, while adjusting for baseline values. All tests were two sided, with alpha set to 0.05.

Results

Sixty children including 38 boys and 22 girls were enrolled in this study. In all three groups, postural stability and coordination improved significantly in terms of modified clinical test of sensory integration of balance, center of pressure, limits of stability, bilateral coordination, and upper-limb coordination.

Conclusion

The current study supports the value of adding postural stability and coordination training to the physiotherapy plan for children with posterior fossa tumor.

Trial registration number and date of registration

ClinicalTrials.gov Identifier: NCT04528316 on August 27, 2020.

Effects of a social participation-focused virtual reality intervention for community-dwelling stroke survivors with physical disabilities: a randomised controlled trial protocol

INTRODUCTION

Studies show that stroke survivors encounter physical and psychological limitations that restrict their participation in social and community activities. Systematic reviews have yielded inconclusive evidence regarding the effectiveness of different interventions intended to support stroke survivors' social participation. Recent advances in virtual reality technology may offer promising solutions, although the optimal approach to enhance social participation among stroke survivors is yet to be determined. This trial aims to develop and evaluate the effectiveness of a social participation-focused virtual reality (SP-VR) intervention on the physical, psychological and social outcomes of community-dwelling stroke survivors with physical disabilities.

METHODS AND ANALYSIS

A two-arm randomised, controlled, assessor-blind clinical trial will be conducted with 250 stroke survivor-caregiver dyads recruited from three acute and one rehabilitation hospitals, and three stroke nurse-led clinics. Participants will be survivors of a first or recurrent stroke within 6 months of stroke onset and able to remain in a sitting position without support, and their primary caregivers. Eligible participants will be randomly allocated to receive the SP-VR intervention or usual care which includes conventional physical therapy services. The intervention group will receive a newly developed 6-week novel custom-made SP-VR application comprising two sessions weekly. Three SP-VR modules will cover key aspects of survivors' social health needs, namely functional rehabilitation, social participation, and social interaction and recreation. The primary outcome for stroke survivors is social participation, and secondary outcomes include depressive symptoms, participation self-efficacy, physical function, functional mobility and social support. User satisfaction will be evaluated among both survivors and caregivers. Data will be collected in person at baseline, immediately after, and 3 months postintervention.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Research Ethics Committee (Ref. No.: 2019.676). Study results will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2100050850.

Effects of Immersive and Non-Immersive Virtual Reality on the Static and Dynamic Balance of Stroke Patients: A Systematic Review and Meta-Analysis

(1) Background: The development of new technologies means that the use of virtual reality is increasingly being implemented in rehabilitative approaches for adult stroke patients.

OBJECTIVE

To analyze the existing scientific evidence regarding the application of immersive and non-immersive virtual reality in patients following cerebrovascular incidents and their efficacy in achieving dynamic and static balance. (2) Data sources: An electronic search of the databases Medline, Cochrane Library, PEDro, Scopus, and Scielo from January 2010 to December 2020 was carried out using the terms physiotherapy, physical therapy, virtual reality, immersive virtual reality, non-immersive virtual reality, stroke, balance, static balance, and dynamic balance.

SELECTION OF STUDIES

Randomized controlled trials in patients older than 18 developed with an adult population (>18 years old) with balance disorders as a consequence of suffering a stroke in the previous six months before therapeutic intervention, including exercises harnessing virtual reality in their interventions and evaluations of balance and published in English or Spanish, were included. A total of two hundred twenty-seven articles were found, ten of which were included for review and of these, nine were included in the subsequent meta-analysis. (3) Data extraction: Two authors selected the studies and extracted their characteristics (participants, interventions, and validation instruments) and results. The methodological quality of the studies was evaluated using the PEDro scale, and the risk of bias was determined using the Cochrane risk-of-bias tool.

DATA SYNTHESIS

Of the selected studies, three did not show significant improvements and seven showed significant improvements in the intervention groups in relation to the variables. (4) Conclusions: Non-immersive virtual reality combined with conventional rehabilitation could be considered as a therapeutic option.

VIRTUAL REALITY TRAINING THROUGH NINTENDO WII GAMES IN STROKE PATIENTS: A RANDOMISED CLINICAL TRIAL (Preprint)

Background

Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial.

Objective

The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke.

Methods

It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22.

Results

The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted.

Conclusions

VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability.

Trial Registration

Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view

Biofeedback for Post-stroke Gait Retraining: A Review of Current Evidence and Future Research Directions in the Context of Emerging Technologies

Real-time gait biofeedback is a promising rehabilitation strategy for improving biomechanical deficits in walking patterns of post-stroke individuals. Because wearable sensor technologies are creating avenues for novel applications of gait biofeedback, including use in tele-health, there is a need to evaluate the state of the current evidence regarding the effectiveness of biofeedback for post-stroke gait training. The objectives of this review are to: (1) evaluate the current state of biofeedback literature pertaining to post-stroke gait training; and (2) determine future research directions related to gait biofeedback in context of evolving technologies. Our overall goal was to determine whether gait biofeedback is effective at improving stroke gait deficits while also probing why and for whom gait biofeedback may be an efficacious treatment modality. Our literature review showed that the effects of gait biofeedback on post-stroke walking dysfunction are promising but are inconsistent in methodology and therefore results. We summarize sources of methodological heterogeneity in previous literature, such as inconsistencies in feedback target, feedback mode, dosage, practice structure, feedback structure, and patient characteristics. There is a need for larger-sample studies that directly compare different feedback parameters, employ more uniform experimental designs, and evaluate characteristics of potential responders. However, as these uncertainties in existing literature are resolved, the application of gait biofeedback has potential to extend neurorehabilitation clinicians' cues to individuals with post-stroke gait deficits during ambulation in clinical, home, and community settings, thereby increasing the quantity and quality of skilled repetitions during task-oriented stepping training. In addition to identifying gaps in previous research, we posit that future research directions should comprise an amalgam of mechanism-focused and clinical research studies, to develop evidence-informed decision-making guidelines for gait biofeedback strategies that are tailored to individual-specific gait and sensorimotor impairments. Wearable sensor technologies have the potential to transform gait biofeedback and provide greater access and wider array of options for clinicians while lowering rehabilitation costs. Novel sensing technologies will be particularly valuable for telehealth and home-based stepping exercise programs. In summary, gait biofeedback is a promising intervention strategy that can enhance efficacy of post-stroke gait rehabilitation in both clinical and tele-rehabilitation settings and warrants more in-depth research.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

LIMITATIONS

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

SUMMARY

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

DISCLAIMER

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

Walking Gait Mechanics and Gaze Fixation in Individuals With Chronic Ankle Instability

CONTEXT

Many individuals who suffer a lateral ankle sprain will develop chronic ankle instability (CAI). Individuals with CAI demonstrate kinematic differences in walking gait, as well as somatosensory alterations compared with healthy individuals. However, the role of vision during walking gait in this population remains unclear.

OBJECTIVE

To evaluate ankle kinematics, gaze deviations, and gaze velocity between participants with CAI and healthy controls while walking on a treadmill during 3 separate visual conditions (no target, fixed target, and moving target).

DESIGN

Case-control study.

SETTING

Laboratory. Patients (or Other Participants): Ten CAI participants and 10 healthy matched controls participated.

MAIN OUTCOME MEASURES

Ankle sagittal and frontal plane kinematics were analyzed for the entire gait cycle. Average and standard deviation (SD) for gaze deviation and gaze velocity were calculated in the horizontal (X) and vertical (Y) planes.

RESULTS

No significant differences were found between groups for either ankle kinematics or gaze variables; however, large effect sizes were found in the no target condition for average deviation of X (healthy 0.05 [0.02], CAI 0.12 [0.11]). Moderate effect sizes were identified in the no target condition for SD of Y (healthy 0.04 [0.03], CAI 0.11 [0.15]) and the moving target condition for average velocity of X (healthy 1.56 [0.73], CAI 2.27 [1.15]) and Y (healthy 1.07 [0.51], CAI 1.47 [0.52]).

CONCLUSIONS

Although no significant differences were found between groups, it is possible that the role of vision in individuals with CAI may be altered with a more difficult task.

Immersive Virtual Reality in Stroke Patients as a New Approach for Reducing Postural Disabilities and Falls Risk: A Case Series

Stroke is a neurologic disorder considered the first cause of disability worldwide due to motor, cognitive, and sensorial sequels. Balance dysfunctions in stroke survivors increase the risk of falls and physiotherapeutic rehabilitation is essential to reduce it. Virtual reality (VR) seems to be an alternative to conventional physiotherapy (CT), providing virtual environments and multisensorial inputs to train balance in stroke patients. The aim of this study was to assess if immersive VR treatment is more effective than CT to improve balance after stroke. This study got the approval from the Ethics Committee of the University of Almeria. Three chronic ischemic stroke patients were selected. One patient who received 25 sessions of immersive VR intervention for two months was compared with another patient who received equivalent CT and a third patient with no intervention. Balance, gait, risk of falling, and vestibular and visual implications in the equilibrium were assessed. After the interventions, the two patients receiving any of the treatments showed an improvement in balance compared to the untreated patient. In comparison to CT, our results suggest a higher effect of immersive VR in the improvement of balance and a reduction of falls risk due to the active upright work during the VR intervention.

The Effects of Posterior Talar Glide and Dorsiflexion of the Ankle Plus Mobilization with Movement on Balance and Gait Function in Patient with Chronic Stroke: A Randomized Controlled Trial

Background:

This study was to evaluate the effects of weight-bearing-based mobilization with movement (WBBMWM) on balance and gait in stroke patients.

Methods:

Thirty stroke patients participated in this study. All individuals were randomly assigned to either WBMWM group (n = 15) or weight-bearing with placebo mobilization with movement group (control, n = 15). Individuals in the WBMWM group were trained for 10 glides of 5 sets a day, 5 times a week during 4 weeks. Furthermore, individuals in the control group were trained for 10 lunges of 5 sets a day, 5 times a week during 4 weeks. All individuals were measured weight-bearing lunge test (WBLT), static balance ability, timed up and go test (TUG), and dynamic gait index (DGI) in before and after intervention.

Results:

The result showed that WBBMWM group and control group had significantly increased in WBLT, postural sway speed, total postural sway path length with eyes open and closed, TUG and DGI (P < 0.05). In particular, the WBMWM group showed significantly greater improvement than control group in WBLT, static balance measures, TUG, and DGI (P < 0.05).

Conclusion:

Therefore, WBMWM improved ankle range of motion, balance, and gait in stroke patients. These results suggest that WBBMWM is feasible and suitable for individuals with a stroke.

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

OBJECTIVE

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

SETTING

Home-based exercise program (HEP).

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interactive Video Gaming Improves Functional Balance in Poststroke Individuals: Meta-Analysis of Randomized Controlled Trials

The main objective of this study was to evaluate the effects of interactive video games on functional balance and mobility in poststroke individuals. The Health Science databases accessed included Medline via PubMed, LILACS, SciELO, and PEDro. The inclusion criteria were as follows: clinical studies evaluating the use of interactive video games as a treatment to improve functional balance and mobility in individuals poststroke and studies published in the Brazilian Portuguese, English, or Spanish language between 2005 and April 2016. PEDro Scale was used to analyze the methodological quality of the studies. The Berg Balance Scale and Timed Up and Go Test (TUGT) data were evaluated using a meta-analysis, the publication bias was assessed by funnel plots, and the heterogeneity of the studies by I ² statistic. Eleven studies were included in the final analysis. Functional balance improved in individuals treated using interactive video games (mean difference = 2.24, 95% confidence interval [0.45, 4.04], p = .01), but no improvement was observed in mobility as measured by TUGT. The studies presented low heterogeneity (24%). The mean score on the PEDro Scale was 6.2 ± 1.9. Interactive video games were effective in improving functional balance but did not influence the mobility of individuals poststroke.

Virtual reality for stroke rehabilitation

BACKGROUND

Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation with commercial gaming consoles in particular, being rapidly adopted in clinical settings. This is an update of a Cochrane Review published first in 2011 and then again in 2015.

OBJECTIVES

Primary objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity.Secondary objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and seven additional databases. We also searched trials registries and reference lists.

SELECTION CRITERIA

Randomised and quasi-randomised trials of virtual reality ("an advanced form of human-computer interface that allows the user to 'interact' with and become 'immersed' in a computer-generated environment in a naturalistic fashion") in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance and global motor function.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data, and assessed risk of bias. A third review author moderated disagreements when required. The review authors contacted investigators to obtain missing information.

MAIN RESULTS

We included 72 trials that involved 2470 participants. This review includes 35 new studies in addition to the studies included in the previous version of this review. Study sample sizes were generally small and interventions varied in terms of both the goals of treatment and the virtual reality devices used. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains mostly low quality when rated using the GRADE system. Control groups usually received no intervention or therapy based on a standard-care approach.

PRIMARY OUTCOME

results were not statistically significant for upper limb function (standardised mean difference (SMD) 0.07, 95% confidence intervals (CI) -0.05 to 0.20, 22 studies, 1038 participants, low-quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care (providing a higher dose of therapy for those in the intervention group) there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low-quality evidence).

SECONDARY OUTCOMES

when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty-three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild.

AUTHORS' CONCLUSIONS

We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time). There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome. There was a trend suggesting that higher dose (more than 15 hours of total intervention) was preferable as were customised virtual reality programs; however, these findings were not statistically significant.

Cerebral Reorganization in Subacute Stroke Survivors after Virtual Reality-Based Training: A Preliminary Study

Background

Functional magnetic resonance imaging (fMRI) is a promising method for quantifying brain recovery and investigating the intervention-induced changes in corticomotor excitability after stroke. This study aimed to evaluate cortical reorganization subsequent to virtual reality-enhanced treadmill (VRET) training in subacute stroke survivors.

Methods

Eight participants with ischemic stroke underwent VRET for 5 sections per week and for 3 weeks. fMRI was conducted to quantify the activity of selected brain regions when the subject performed ankle dorsiflexion. Gait speed and clinical scales were also measured before and after intervention.

Results

Increased activation in the primary sensorimotor cortex of the lesioned hemisphere and supplementary motor areas of both sides for the paretic foot (p < 0.01) was observed postintervention. Statistically significant improvements were observed in gait velocity (p < 0.05). The change in voxel counts in the primary sensorimotor cortex of the lesioned hemisphere is significantly correlated with improvement of 10 m walk time after VRET (r = −0.719).

Conclusions

We observed improved walking and increased activation in cortical regions of stroke survivors after VRET training. Moreover, the cortical recruitment was associated with better walking function. Our study suggests that cortical networks could be a site of plasticity, and their recruitment may be one mechanism of training-induced recovery of gait function in stroke. This trial is registered with ChiCTR-IOC-15006064.

Effect of Virtual Reality on Postural and Balance Control in Patients with Stroke: A Systematic Literature Review

Objective. To critically evaluate the studies that were conducted over the past 10 years and to assess the impact of virtual reality on static and dynamic balance control in the stroke population. Method. A systematic review of randomized controlled trials published between January 2006 and December 2015 was conducted. Databases searched were PubMed, Scopus, and Web of Science. Studies must have involved adult patients with stroke during acute, subacute, or chronic phase. All included studies must have assessed the impact of virtual reality programme on either static or dynamic balance ability and compared it with a control group. The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies. Results. Nine studies were included in this systematic review. The PEDro scores ranged from 4 to 9 points. All studies, except one, showed significant improvement in static or dynamic balance outcomes group. Conclusions. This review provided moderate evidence to support the fact that virtual reality training is an effective adjunct to standard rehabilitation programme to improve balance for patients with chronic stroke. The effect of VR training in balance recovery is less clear in patients with acute or subacute stroke. Further research is required to investigate the optimum training intensity and frequency to achieve the desired outcome.

Effect of Virtual Reality Training on Balance and Gait Ability in Patients With Stroke: Systematic Review and Meta-Analysis

BACKGROUND

Virtual reality (VR) training is considered to be a promising novel therapy for balance and gait recovery in patients with stroke.

PURPOSE

The aim of this study was to conduct a systematic literature review with meta-analysis to investigate whether balance or gait training using VR is more effective than conventional balance or gait training in patients with stroke.

DATA SOURCES

A literature search was carried out in the databases PubMed, Embase, MEDLINE, and Cochrane Library up to December 1, 2015.

STUDY SELECTION

Randomized controlled trials that compared the effect of balance or gait training with and without VR on balance and gait ability in patients with stroke were included.

DATA EXTRACTION AND SYNTHESIS

Twenty-one studies with a median PEDro score of 6.0 were included. The included studies demonstrated a significant greater effect of VR training on balance and gait recovery after stroke compared with conventional therapy as indicated with the most frequently used measures: gait speed, Berg Balance Scale, and Timed "Up & Go" Test. Virtual reality was more effective to train gait and balance than conventional training when VR interventions were added to conventional therapy and when time dose was matched.

LIMITATIONS

The presence of publication bias and diversity in included studies were limitations of the study.

CONCLUSIONS

The results suggest that VR training is more effective than balance or gait training without VR for improving balance or gait ability in patients with stroke. Future studies are recommended to investigate the effect of VR on participation level with an adequate follow-up period. Overall, a positive and promising effect of VR training on balance and gait ability is expected.

Effects of virtual reality for stroke individuals based on the International Classification of Functioning and Health: a systematic review

OBJECTIVE

This review determines the effects of virtual reality interventions for stroke subjects based on the International Classification of Functioning, Disability,and Health (ICF) framework. Virtual reality is a promising tool for therapy for stroke rehabilitation, but the effects of virtual reality interventions on post-stroke patients based on the specific ICF domains (Body Structures, Body Functions, Activity, and Participation) have not been investigated.

METHOD

A systematic review was conducted, including trials with adults with a clinical diagnosis of a chronic, subacute, or acute stroke. Eligible trials had to include studies with an intervention protocol and follow-up, with a focus on upper limbs and/or lower limbs and/or balance. The Physiotherapy Evidence Database (PEDro) was used to assess the methodological quality of randomized controlled trials. Each trial was separated according to methodological quality into a high-quality trial (PEDro ≥ 6) and a low-quality trial (PEDro ≤ 6). Only high-quality trials were analyzed specifically based on the outcome of these trials.

RESULTS

In total, 54 trials involving 1811 participants were included. Of the papers included and considered high quality, 14 trials evaluated areas of the Body Structures component, 20 trials of the Body Functions domain, 17 trials of the Activity component, and 8 trials of the Participation domain. In relation to ICF Part 2, four trials evaluated areas of the Personal Factors component and one trial evaluated domains of the Environmental Factors component.

DISCUSSION

The effects of virtual reality on stroke rehabilitation based on the ICF framework are positive in Body Function and Body Structure. However, the results in the domains Activity and Participation are inconclusive. More high-quality clinical trials are needed to confirm the effectiveness of virtual reality in the domains of Activity and Participation.

Effect of Mulligan's mobilization with movement technique on gait function in stroke patients

[Purpose] We examined the effectiveness of Mulligan's mobilization with movement (MWM) technique on spatiotemporal variables of gait in individuals who had a stroke. [Subjects and Methods] Twenty-four subjects were randomly divided into 2 groups: Mulligan's mobilization with movement group (n=12) and "weight-bearing with placebo" mobilization with movement group (n=12). The subjects in the mobilization with movement group performed 5 sets of 10 glides a day, 5 times a week for 4 weeks. The mobilization with movement technique comprised grade III movements that involved gliding and resting. The control group subjects performed lunges in the same conditions as those of the experimental group. Gait function was measured in terms of spatiotemporal parameters to determine the effect of mobilization with movement. [Results] The mobilization with movement group showed significant improvements in velocity, cadence, stride length, single-support time, and step length of the affected side, and step length and stride length of the non-affected side. Overall, the mobilization with movement group showed significantly greater improvements than the control group in terms of velocity, cadence, and single-support time of the affected side. [Conclusion] Mobilization with movement can be used to improve the gait function of patients recovering from stroke.

A study of the effect of visual depth information on upper limb movement by use of measurement of smoothness

[Purpose] This study verified that the smoothness of reaching movements is able to quantitatively evaluate the effects of two- and three-dimensional images on movement in healthy people. In addition, clinical data of cerebrovascular accident patients were also analyzed by the same method. [Subjects] Ten healthy adult volunteers and two male patients with previous cerebrovascular accidents participated. [Methods] The subjects were tasked with reaching for objects shown on a display. The target and virtual limb, rendered with computer graphics, were shown on the display. Movements of the virtual limb were synchronized with those of the subject. Healthy subjects reached for targets with their dominant arm, and cerebrovascular accident patients used their paretic arm. A polarized display and polarized glasses were used when the subjects were shown three-dimensional images. In the present study, jerk cost was used to quantify the smoothness of movement. [Results] Six of the 10 healthy subjects had significantly smoother reaching movements when viewing the three-dimensional images. The two cerebrovascular accident patients tended to have smoother movements in response to the three-dimensional images. [Conclusion] Analysis of the smoothness of movement was able to detect the influence of the depth cue in vision on movement quantitatively for the healthy subjects and cerebrovascular accident patients.

Virtual reality for improving balance in patients after stroke: A systematic review and meta-analysis

Objective:

To evaluate the effectiveness of virtual reality interventions for improving balance in people after stroke.

Design:

Systematic review and meta-analysis of randomized controlled trials.

Methods:

Studies were obtained by searching the following databases: MEDLINE, CINAHL, EMBASE, Web of Science and CENTRAL. Two reviewers assessed studies for inclusion, extracted data and assessed trial quality.

Results:

Sixteen studies involving 428 participants were included. People who received virtual reality interventions showed marked improvements in Berg Balance Scale (mean difference: 1.46, 95% confidence interval: 0.09–2.83, P<0.05, I²=0%) and Timed Up and Go Test (mean difference: –1.62, 95% confidence interval: –3.07– –0.16, P<0.05, I²=24%) compared with controls.

Conclusions:

This meta-analysis of randomized controlled trials supports the use of virtual reality to improve balance after stroke.