Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy

Areas of Research Focus and Trends in the Research on the Application of VR in Rehabilitation Medicine

OBJECTIVE

To establish the areas of research focus in the application of VR in rehabilitation medicine, analyze its themes and trends, and offer a reference for future related research in this field.

METHODS

This paper provides an in-depth analysis of the development process, areas of research focus, and research trends in the field of the application of VR in rehabilitation medicine, using the Web of Science core dataset as the source and using a bibliometric analysis with CiteSpace.

RESULTS

The application of VR in rehabilitation medicine was composed of three stages, and the research topics were reviewed from five perspectives: neurological rehabilitation, psychological treatment, pain distraction, cardiopulmonary rehabilitation, and visual-spatial disorder.

LIMITATIONS

The research data were sourced from the Web of Science core dataset only, and the data-sample size was not comprehensive.

CONCLUSIONS

Overcoming VR-technology-induced vertigo, mental disorders from the overuse of VR, individualized treatments, and integration with traditional therapy are all challenges in the application of VR in rehabilitation medicine that require research. In addition, developing VR products with better experiences, constructing standardized guidelines, and conducting more high-quality clinical studies are all future research topics related to the application of VR in rehabilitation medicine.

Comparative efficacy of gait training for balance outcomes in patients with stroke: A systematic review and network meta-analysis

Background

Growing evidence suggests that gait training can improve stroke patients’ balance outcomes. However, it remains unclear which type of gait training is more effective in improving certain types of balance outcomes in patients with stroke. Thus, this network meta-analysis (NMA) included six types of gait training (treadmill, body-weight-supported treadmill, virtual reality gait training, robotic-assisted gait training, overground walking training, and conventional gait training) and four types of balance outcomes (static steady-state balance, dynamic steady-state balance, proactive balance, and balance test batteries), aiming to compare the efficacy of different gait training on specific types of balance outcomes in stroke patients and determine the most effective gait training.

Method

We searched PubMed, Embase, Medline, Web of Science, and Cochrane Library databases from inception until 25 April 2022. Randomized controlled trials (RCTs) of gait training for the treatment of balance outcomes after stroke were included. RoB2 was used to assess the risk of bias in the included studies. Frequentist random-effects network meta-analysis (NMA) was used to evaluate the effect of gait training on four categories of balance outcomes.

Result

A total of 61 RCTs from 2,551 citations, encompassing 2,328 stroke patients, were included in this study. Pooled results showed that body-weight-support treadmill (SMD = 0.30, 95% CI [0.01, 0.58]) and treadmill (SMD = 0.25, 95% CI [0.00, 0.49]) could improve the dynamic steady-state balance. Virtual reality gait training (SMD = 0.41, 95% CI [0.10, 0.71]) and body-weight-supported treadmill (SMD = 0.41, 95% CI [0.02, 0.80]) demonstrated better effects in improving balance test batteries. However, none of included gait training showed a significant effect on static steady-state balance and proactive balance.

Conclusion

Gait training is an effective treatment for improving stroke patients’ dynamic steady-state balance and balance test batteries. However, gait training had no significant effect on static steady-state balance and proactive balance. To achieve maximum efficacy, clinicians should consider this evidence when recommending rehabilitation training to stroke patients. Considering body-weight-supported treadmill is not common for chronic stroke patients in clinical practice, the treadmill is recommended for those who want to improve dynamic steady-state balance, and virtual reality gait training is recommended for those who want to improve balance test batteries.

Limitation

Missing evidence in relation to some types of gait training is supposed to be taken into consideration. Moreover, we fail to assess reactive balance in this NMA since few included trials reported this outcome.

Systematic Review Registration

PROSPERO, identifier CRD42022349965.

A Study on Rehabilitation Specialists’ Perception of Experience with a Virtual Reality Program

This study aimed to analyse the types and characteristics of rehabilitation specialists’ experience in administering virtual reality (VR) programs using Q methodology as well as provide basic data regarding the introduction of VR programs in rehabilitation therapy. Thirty-three statements were derived based on a literature review and an in-depth interview with rehabilitation specialists. Q-sorting was performed by a Q-sample of 22 rehabilitation specialists with experience administering VR programs. Data were analysed using the QUANL Program. Rehabilitation specialists’ experience with administering VR programs were classified into three types: type 1 was labelled ‘the need to develop VR programs customised for disability level and type’, type 2 was labelled ‘emphasis on experts’ role of paying attention continuously and their experience’, and type 3 was labelled ‘the need to develop safety equipment by disability type’. The study’s findings demonstrate that there are a variety of rehabilitation specialists’ perceptions on their experience administering VR programs. This study is of significance because it suggests ways to improve VR programs for disabled people, with the consultation of rehabilitation specialists. In addition, rehabilitation specialists’ perceptions on VR programs have not been explored before.

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 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.

The Effect of Augmented Reality-Based Proprioceptive Training Program on Balance, Positioning Sensation and Flexibility in Healthy Young Adults: A Randomized Controlled Trial

This study investigates whether Augmented Reality (AR)-based interventions can be as effective as physical therapists (PT) regarding balance, positioning sensation, and flexibility. A sample of 39 regular people who voluntarily participated in this study were randomly distributed into two groups. Then AR was applied in the experimental group and PT was applied in the control group. Variables were measured by Tetrax (static balance), Y-balance test (dynamic balance), CSMI (proprioception), and sit and reach test (flexibility). All measurements were analyzed using paired t-test and independent t-test. The exercise program of this study improved the stability index (ST) of the static balance in both groups after the intervention, and there was a significant difference (p < 0.05) at normal eye close (NC) and Pillow with eye close (PC) positions. Moreover, regarding the case of dynamic balance, there were significant differences in AR and PT groups to reach in all directions (p < 0.05). In the case of positioning sensation, there was no significant difference in both groups (p > 0.05), and there was a significant difference in flexibility (p < 0.05). When comparing the two groups, there was no significant difference in all categories (p > 0.05). As a result, AR can be considered an effective form of therapy and can be selected according to individual conditions.

A Novel Approach to Increase Attention during Mirror Therapy among Stroke Patients: A Video-Based Behavioral Analysis

Stroke is a major cause of disability and an evident rehabilitation strategy is crucial. Mirror therapy (MT) is one of the popular rehabilitation methods that is known to be effective as the patients benefit from the mirror illusion. However, the patient’s attention to the mirror illusion during treatment is unclear. Therefore, the present study assesses the duration and frequency of the mirror gaze, distraction, and preparation of sixteen stroke patients during two MT methods using a behavioral coding software. During the 30 min treatment, the total mirror gaze duration during conventional bilateral MT (BMT) was 564.04 s, while it was 1482.45 s in unilateral MT using a screen (UMT). The total distracted time was 945.61 s in BMT, while it was only 162.03 s in UMT. The total preparatory duration was 290.35 s in BMT and 155.53 s in UMT. The total number of distracted bouts were 136.45 in BMT, while it was 73.38 in UMT. The total number of preparatory bouts were 18.42 in BMT and 9.56 in UMT. The average times of gaze duration per bout were 5.52 s in BMT and 21.81 s in UMT. The average times of distraction per bout were 9.22 s in BMT and 3.00 s in UMT. The total number of mirror gaze bouts and average time of preparation per bout did not present a statistical significance in the comparisons of the two methods. This study assesses two methods of MT using observational coding software to evaluate the duration and frequency of the mirror gaze during treatment. The results suggest that UMT may be an alternative option to provide MT for stroke patients to increase their attention towards the mirror.

Development and Testing of a Portable Virtual Reality-Based Mirror Visual Feedback System with Behavioral Measures Monitoring

Virtual Reality (VR) is a technology that has been used to provide the Mirror Visual Feedback (MVF) illusion to patients with promising results. In the present work, the goal is to design, develop and test a portable VR-based MVF system that monitors behavioral information about the performance of a simple motor task. The developed application runs in a stand-alone VR system and allows the researcher to select the real and virtual hands used to perform the motor task. The system was evaluated with a group of twenty healthy volunteers (12 men and 8 women) with ages between 18 and 66 years. Participants had to repetitively perform a motor task in four different experimental conditions: two mirror conditions (performing real movements with the dominant and with the non-dominant hand) and two non-mirror conditions. A significant effect of the experimental condition on embodiment score (p < 0.001), response time (p < 0.001), performance time (p < 0.001), trajectory length (p < 0.004) and trajectory maximum horizontal deviation (p < 0.001) was observed. Furthermore, a significant effect of the experimental moment (initial, middle and final parts of the training) on the performance time was observed (p < 0.001). These results show that the monitored parameters provide relevant information to evaluate the participant’s task performance in different experimental conditions.

Telerehabilitation—A Viable Option for the Recovery of Post-Stroke Patients

As the number of stroke survivors is continuously growing, with an important number suffering from consequent functional deficits, the rehabilitation field is facing more complex demands. Technological progress gives us the opportunity to remotely assist patients while they exercise at home through telerehabilitation (TR), addressing the problems of limited medical resources and staff, difficult transportation, or living a long distance from rehabilitation centers. In addition, TR is a way to provide continuity in long-term post-stroke recovery during the COVID-19 pandemic, which limits traveling and human interaction. While the implementation of TR is increasing, the biggest challenges are to raise patients’ acceptability of the new method and their motivation and engagement during the program. In this review, we aimed to find methods to address these challenges by identifying the patients who benefit the most from this therapy and efficiently organizing the space and technology used for telerehabilitation. User-friendly technologies and devices along with therapists’ constant support and feedback are some of the most important aspects that make TR an efficient intervention and an alternative to conventional therapy.