Speed-Interactive Pedaling Training Using Smartphone Virtual Reality Application for Stroke Patients: Single-Blinded, Randomized Clinical Trial

The Technology to Enhance Patient Motivation in Virtual Reality Rehabilitation: A Review

Virtual reality (VR) technology has experienced a steady rise and has been widely applied in the field of rehabilitation. The integration of VR technology in rehabilitation has shown promising results in enhancing their motivation for treatment, thereby enabling patients to actively engage in rehab training. Despite the advancement, there is a dearth of comprehensive summary and analysis on the use of VR technology to enhance patient motivation in rehabilitation. Thus, this narrative review aims to evaluate the potential of VR technology in enhancing patient motivation during motor rehabilitation training. This review commences with an explanation of how enhancing motivation through the VR rehabilitation system could improve the efficiency and effectiveness of rehabilitation training. Then, the technology was analyzed to improve patient motivation in the present VR rehabilitation system in detail. Furthermore, these technologies are classified and summarized to provide a comprehensive overview of the state-of-the-art approaches for enhancing patient motivation in VR rehabilitation. Findings showed VR rehabilitation training utilizes game-like exercises to enhance the engagement and enjoyment of rehabilitation training. By immersing patients in a simulated environment with multisensory feedback, VR systems offer a unique approach to rehabilitation that can lead to improved patient motivation. Both ultimately lead to improved patient outcomes, which is not typically achievable with traditional rehabilitation methods. The review concludes that VR rehabilitation presents an opportunity to improve patient motivation and adherence to long-term rehabilitation training. However, to further enhance patient self-efficacy, VR rehabilitation should integrate psychology and incorporate methods. Moreover, it is necessary to build a game design theory for rehabilitation games, and the latest VR feedback technology should also be introduced.

Effects of trunk exercises using virtual reality technology on trunk performance and impairment post stroke: a systematic review and meta-analysis

OBJECTIVE

To systematically explore the effects of trunk exercises using virtual reality technology compared to conventional exercises for trunk impairment in patients with subacute and chronic strokes.

METHODS

A comprehensive search of literature published from inception until December 2022 was conducted using PubMed, Cochrane Library, Web of Science, Scopus, IEEE, and the Physiotherapy Evidence Database (PEDro). The inclusion criteria encompassed all randomized controlled trials (RCT) published in the English language involving adults who had had strokes and the evaluation of the effectiveness of virtual reality -based trunk exercises in reducing trunk impairment post stroke as measured by the trunk control test (TCT) and/or the trunk impairment scale (TIS) compared to conventional trunk exercises.

RESULT

A total of 397 studies were retrieved, and six studies were included in the current analysis. A random-effects meta-analysis of six studies indicated that video games had a very large, significant effect (SMD = 1.11; 95%, P < 0.0001) on the delivery of trunk exercises to reduce trunk impairment post stroke at both the subacute and chronic stages.

CONCLUSION

The study findings indicate that trunk exercises using virtual reality have a highly significant effect on reducing trunk impairment in patients with subacute and chronic stroke. Large RCTs are needed to study the effects of virtual reality trunk exercises on the acute, subacute, and chronic stages of stroke.

Effectiveness of mobile application interventions for stroke survivors: systematic review and meta-analysis

BACKGROUND

Although smartphone usage is ubiquitous, and a vast amount of mobile applications have been developed for chronic diseases, mobile applications amongst stroke survivors remain unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to determine the effectiveness of mobile applications on medication adherence, functional outcomes, cardiovascular risk factors, quality of life and knowledge on stroke in stroke survivors.

METHODS

A review of the literature was conducted using key search terms in PubMed, EMBASE, Cochrane and Web of Science databases until 16 March 2023 to identify eligible randomized controlled trials (RCTs) or controlled clinical trial (CCTs) of mobile application interventions among stroke survivors. Two reviewers independently screened the literature in accordance with the eligibility criteria and collected data from the articles included. Outcomes included medication adherence,functional outcomes,cardiovascular risk factors, quality of life,and knowledge of stroke.

RESULTS

Twenty-three studies involving 2983 participants across nine countries were included in this review. Sixteen trials involved health care professionals in app use, and seven trials reported measures to ensure app-based intervention adherence. Mobile applications targeting stroke survivors primarily encompassed three areas: rehabilitation, education and self-care. The participants in the studies primarily included young and middle-aged stroke survivors. Meta-analysis results demonstrated that mobile application intervention significantly improved trunk control ability (mean differences [MD] 3.00, 95% CI [1.80 to 4.20]; P < 0.00001), Fugl-Meyer assessment of upper extremity (MD 9.81, 95% CI [8.72 to 10.90]; P < 0.00001), low-density lipoprotein cholesterol (MD - 0.33, 95% CI [- 0.54 to - 0.11]; P = 0.003) and glycosylated haemoglobin A1c (HbA1c)<7 levels (MD 1.95, 95% CI [1.17 to 3.25]; P = 0.01). However, the mobile application intervention did not differ significantly in medication adherence, 10-min walk test (10 MWT), Barthel index, systolic blood pressure, diastolic blood pressure, high-density lipoprotein cholesterol, body mass index, smoking, health-related quality of life and knowledge of stroke.

CONCLUSION

Our study suggested that mobile application interventions may have a potential benefit to stroke survivors, but clinical effectiveness should be established. More studies using rigorous designs are warranted to understand their usefulness. Future research should also involve more older adult stroke survivors.

Virtual reality-based gait rehabilitation intervention for stroke individuals: a scoping review

Virtual reality (VR)-based rehabilitation is rapidly gaining interest and has been shown to be an intervention to facilitate motor learning in balance and gait rehabilitation. A review of the current literature is needed to provide an overview of the current state of knowledge of VR-based gait physiotherapy for stroke patients. A systematic literature search was performed in PubMed and Scopus. Search terms included: "virtual reality," "stroke," "gait," and "physical therapy." Articles published in a peer-reviewed journal between 2017 and 2021 were considered. The intervention was mainly related to the use of VR as a therapeutic modality, and the outcome was gait performance. The initial search identified 329 articles. After an eligibility review, 13 articles that met the inclusion criteria were included in the study. Most of participants were in a chronic stage and were between 14 and 85 years old. The VR-based gait training ranged from nonimmersive to immersive, was mostly performed on a treadmill, and was usually combined with conventional physiotherapy. The duration of the program varied from 10 to 60 min, and there were about 9 to 30 sessions. VR-based gait rehabilitation has a positive effect on gait ability. The existing literature suggests that VR-based rehabilitation combined with conventional physiotherapy could improve gait ability of people with stroke, especially in the chronic stage. However, the duration of VR-based programs should be customized to suit individuals to avoid stimulation sickness. Further research is needed to investigate the long-term effects of this approach.

Clinical Study of a Wearable Remote Rehabilitation Training System for Patients With Stroke: Randomized Controlled Pilot Trial

BACKGROUND

In contrast to the large and increasing number of patients with stroke, clinical rehabilitation resources cannot meet their rehabilitation needs. Especially for those discharged, ways to carry out effective rehabilitation training without the supervision of physicians and receive guidance from physicians remain urgent problems to be solved in clinical rehabilitation and have become a research hot spot at home and abroad. At present, there are many studies on home rehabilitation training based on wearable devices, Kinect, among others, but these have disadvantages (eg, complex systems, high price, and unsatisfactory rehabilitation effects).

OBJECTIVE

This study aims to design a remote intelligent rehabilitation training system based on wearable devices and human-computer interaction training tasks, and to evaluate the effectiveness and safety of the remote rehabilitation training system for nonphysician-supervised motor rehabilitation training of patients with stroke through a clinical trial study.

METHODS

A total of 120 inpatients with stroke having limb motor dysfunction were enrolled via a randomized, parallel-controlled method in the rehabilitation institutions, and a 3-week clinical trial was conducted in the rehabilitation hall with 60 patients in the experimental group and 60 in the control group. The patients in the experimental group used the remote rehabilitation training system for rehabilitation training and routine clinical physical therapy (PT) training and received routine drug treatment every day. The patients in the control group received routine clinical occupational therapy (OT) training and routine clinical PT training and routine drug treatment every day. At the beginning of the training (baseline) and after 3 weeks, the Fugl-Meyer Motor Function Rating scale was scored by rehabilitation physicians, and the results were compared and analyzed.

RESULTS

Statistics were performed using SAS software (version 9.4). The total mean Fugl-Meyer score improved by 11.98 (SD 8.46; 95% CI 9.69-14.27) in the control group and 17.56 (SD 11.65; 95% CI 14.37-20.74) in the experimental group, and the difference between the 2 groups was statistically significant (P=.005). Among them, the mean Fugl-Meyer upper extremity score improved by 7.45 (SD 7.24; 95% CI 5.50-9.41) in the control group and 11.28 (SD 8.59; 95% CI 8.93-13.62) in the experimental group, and the difference between the 2 groups was statistically significant (P=.01). The mean Fugl-Meyer lower extremity score improved by 4.53 (SD 4.42; 95% CI 3.33-5.72) in the control group and 6.28 (SD 5.28; 95% CI 4.84-7.72) in the experimental group, and there was no significant difference between the 2 groups (P=.06). The test results showed that the experimental group was better than the control group, and that the patients' motor ability was improved.

CONCLUSIONS

The remote rehabilitation training system designed based on wearable devices and human-computer interaction training tasks can replace routine clinical OT training. In the future, through medical device registration certification, the system will be used without the participation of physicians or therapists, such as in rehabilitation training halls, and in remote environments, such as communities and homes.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200061310; https://tinyurl.com/34ka2725.

A non-immersive virtual reality-based intervention to enhance lower-extremity motor function and gait in patients with subacute cerebral infarction: A pilot randomized controlled trial with 1-year follow-up

Introduction

This study was conducted to evaluate whether a non-immersive virtual reality (VR)-based intervention can enhance lower extremity movement in patients with cerebral infarction and whether it has greater short-term and long-term effectiveness than conventional therapies (CTs).

Materials and methods

This was a single-blinded, randomized clinical controlled trial. Forty-four patients with subacute cerebral infarction were randomly allocated to the VR or CT group. All intervention sessions were delivered in the inpatient unit for 3 weeks. Outcomes were measured before (baseline) and after the interventions and at 3-month, 6-month and 1-year follow-ups. The outcomes included clinical assessments of movement and balance function using the Fugl–Meyer Assessment of Lower Extremity (FMA-LE) and Berg Balance Scale (BBS), and gait parameters in the sagittal plane.

Results

In the VR group, the walking speed after intervention, at 3-month, 6-month, and 1-year follow-ups were significantly greater than baseline (p = 0.01, <0.001, 0.007, and <0.001, respectively). Compared with baseline, BBS scores after intervention, at 3-month, 6-month, and 1-year follow-ups were significantly greater in both the VR group (p = 0.006, 0.002, <0.001, and <0.001, respectively) and CT group (p = <0.001, 0.002, 0.001, and <0.001, respectively), while FMA-LE scores after intervention, at 3-month, 6-month, and 1-year follow-ups were significant increased in the VR group (p = 0.03, <0.001, 0.003, and <0.001, respectively), and at 3-month, 6-month, and 1-year follow-ups in the CT group (p = 0.02, 0.004 and <0.001, respectively). In the VR group, the maximum knee joint angle in the sagittal plane enhanced significantly at 6-month follow-up from that at baseline (p = 0.04).

Conclusion

The effectiveness of the non-immersive VR-based intervention in our study was observed after the intervention and at the follow-ups, but it was not significantly different from that of CTs. In sum, our results suggest that non-immersive VR-based interventions may thus be a valuable addition to conventional physical therapies to enhance treatment efficacy.

Clinical trial registration

http://www.chictr.org.cn/showproj.aspx?proj=10541, ChiCTR-IOC-15006064.

Virtual reality for limb motor function, balance, gait, cognition and daily function of stroke patients: A systematic review and meta-analysis

AIMS

To explore the beneficial effects of virtual reality (VR) interventions on upper- and lower-limb motor function, balance, gait, cognition and daily function outcomes in stroke patients.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

DATA SOURCES

English databases (PubMed, EMBASE, the Cochrane Library, CINAHL, Web of Science, Physiotherapy Evidence Database, ProQuest Dissertations and Theses) and Chinese databases (Chinese BioMedical Literature Service System, WANFANG, CNKI) and the Clinical Trial Registry Platform were systematically searched from inception until December 2019. Additionally, reference lists of the included studies were manually searched.

REVIEW METHODS

The methodological quality of studies was scored with the Cochrane 'risk-of-bias tool' and PEDro scale from the Physiotherapy Evidence Database by two independent evaluators.

RESULTS

In total, 87 studies with 3540 participants were included. Stroke patients receiving VR interventions showed significant improvements in Fugl-Meyer assessment of Upper Extremity, Action Research Arm Test, Wolf Motor Function Test, Fugl-Meyer Assessment of Lower Extremity, Functional Ambulation Classification, Berg Balance Scale, Time Up and Go, Velocity, Cadence, Modified Barthel Index and Functional Independence Measure. However, differences between VR intervention and traditional rehabilitation groups were not significant for Box-Block Test, 10 m Walk Test, Auditory Continuous Performance Test, Mini-Mental State Examination and Visual Continuous Performance Test.

CONCLUSION

This review suggests that VR interventions effectively improve upper- and lower-limb motor function, balance, gait and daily function of stroke patients, but have no benefits on cognition.

IMPACT

This review identified the positive effects of VR-assisted rehabilitation on upper- and lower-limb motor function, balance, gait and daily function of stroke patients. And, we verified the duration of VR intervention affects some health benefits. The benefit of VR on cognitive function requires further investigation through large-scale multicentre RCTs.

Non-Immersive Virtual Reality for Post-Stroke Upper Extremity Rehabilitation: A Small Cohort Randomized Trial

Immersive and non-immersive virtual reality (NIVR) technology can supplement and improve standard physiotherapy and neurorehabilitation in post-stroke patients. We aimed to use MIRA software to investigate the efficiency of specific NIVR therapy as a standalone intervention, versus standardized physiotherapy for upper extremity rehabilitation in patients post-stroke. Fifty-five inpatients were randomized to control groups (applying standard physiotherapy and dexterity exercises) and experimental groups (applying NIVR and dexterity exercises). The two groups were subdivided into subacute (six months to four years post-stroke survival patients). The following standardized tests were applied at baseline and after two weeks post-therapy: Fugl-Meyer Assessment for Upper Extremity (FMUE), the Modified Rankin Scale (MRS), Functional Independence Measure (FIM), Active Range of Motion (AROM), Manual Muscle Testing (MMT), Modified Ashworth Scale (MAS), and Functional Reach Test (FRT). The Kruskal-Wallis test was used to determine if there were significant differences between the groups, followed with pairwise comparisons. The Wilcoxon Signed-Rank test was used to determine the significance of pre to post-therapy changes. The Wilcoxon Signed-Rank test showed significant differences in all four groups regarding MMT, FMUE, and FIM assessments pre- and post-therapy, while for AROM, only experimental groups registered significant differences. Independent Kruskal-Wallis results showed that the subacute experimental group outcomes were statistically significant regarding the assessments, especially in comparison with the control groups. The results suggest that NIVR rehabilitation is efficient to be administered to post-stroke patients, and the study design can be used for a further trial, in the perspective that NIVR therapy can be more efficient than standard physiotherapy within the first six months post-stroke.