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

Impact of the combination of virtual reality and noninvasive brain stimulation on the upper limb motor function of stroke patients: a systematic review and meta-analysis

BACKGROUND

Stroke frequently results in upper limb motor dysfunction, with traditional therapies often failing to yield sufficient improvements. Emerging technologies such as virtual reality (VR) and noninvasive brain stimulation (NIBS) present promising new rehabilitation possibilities.

OBJECTIVES

This study systematically reviews and meta-analyses the effectiveness of VR and NIBS in improving upper limb motor function in stroke patients.

METHODS

Registered with PROSPERO (CRD42023494220) and adhering to the PRISMA guidelines, this study conducted a thorough search of databases including PubMed, MEDLINE, PEDro, REHABDATA, EMBASE, Web of Science, Cochrane, CNKI, Wanfang, and VIP from 2000 to December 1, 2023, to identify relevant studies. The inclusion criterion was stroke patients receiving combined VR and NIBS treatment, while exclusion criteria were studies with incomplete articles and data. The risk of bias was assessed using the Cochrane Collaboration tool. Statistical analysis was performed using Stata SE 15.0, employing either a fixed-effects model or a random-effects model based on the level of heterogeneity.

RESULTS

A total of 11 studies involving 493 participants were included, showing a significant improvement in Fugl-Meyer Assessment Upper Extremity (FMA-UE) scores in the combined treatment group compared to the control group (SMD = 0.85, 95% CI [0.40, 1.31], p = 0.017). The Modified Ashworth Scale (MAS) scores significantly decreased (SMD = - 0.51, 95% CI [- 0.83, - 0.20], p = 0.032), the Modified Barthel Index (MBI) scores significantly increased (SMD = 0.97, 95% CI [0.76, 1.17], p = 0.004), and the Wolf Motor Function Test (WMFT) scores also significantly increased (SMD = 0.36, 95% CI [0.08, 0.64], p = 0.021). Subgroup analysis indicated that the duration of treatment influenced the outcomes in daily living activities.

CONCLUSIONS

The combination of VR and NIBS demonstrates significant improvements in upper limb motor function in stroke patients. The duration of treatment plays a critical role in influencing the outcomes, particularly in activities of daily living. This systematic review has limitations, including language bias, unclear randomization descriptions, potential study omissions, and insufficient follow-up periods. Future studies should focus on exploring long-term effects and optimizing treatment duration to maximize the benefits of combined VR and NIBS therapy.

The use of virtual reality for activities of daily living rehabilitation after brain injury: A scoping review

INTRODUCTION

Individuals with acquired brain injury (ABI) experience high rates of poor functional outcomes such as inability to complete activities of daily living (ADL). Occupational therapy needs to be customised to the individual's function, goals, and environment to facilitate improvement in ADLs after ABI. Virtual reality (VR) is a novel treatment approach that aims to improve skills within an individualised environment. This study aimed to review the current literature for the use of VR platforms that incorporate ADLs to improve functional outcomes after ABI.

METHODS

This review followed the six-stage framework by Arksey & O'Malley (2005). Electronic databases were searched for peer-reviewed journal articles based on inclusion and exclusion criteria.

RESULTS

One thousand and six hundred eighty articles were screened, including 413 full text articles and 13 articles were included for review. Among the 13 articles, six were RCTs and the rest were pre-post intervention studies. Studies largely used non-immersive VR platforms, which incorporated ADLs such as grocery shopping, aiming to improve functional outcomes.

CONSUMER AND COMMUNITY CONSULTATION

Consumer and community were not involved in executing this study.

CONCLUSION

This review suggests mixed results if VR is effective at treating upper limb, cognition, and ADL function after ABI. Using their clinical reasoning, occupational therapists can determine the suitability of VR for ADL rehabilitation for specific patient populations and settings. Plain Language Summary Individuals who sustain an acquired brain injury can have difficulty performing their daily activities such as, making a meal or getting dressed, because of limited function (e.g., physical and cognitive problems). To help improve their ability to complete daily activities, occupational therapy needs to be customised to the individual's function, goals, and environment. Virtual reality is a new rehabilitation approach that allows individuals to improve their function in an individualised environment. In this study, we reviewed the current studies that have used virtual reality platforms that incorporate daily activities to improve function after acquired brain injury. We searched databases and screened the titles and abstracts of 1,680 studies. Then, 413 full-text studies were screened, and 13 studies were included. Studies mostly used non-immersive platforms to practise daily activities such as, grocery shopping, aiming to improve function after acquired brain injury. This review suggests mixed results if virtual reality can effectively treat function after acquired brain injury.

Seated Virtual Reality-Guided Exercise Improved Gait in a Patient With Trunk Dysfunction Due to Hip Fracture: A Single-Case Design Study

Physical therapy for mobilization after a hip fracture is effective in improving muscle strength and balance training of the lower extremities; however, effective interventions targeting the trunk muscles remain to be established. The efficacy of virtual reality (VR)-based exercise therapy has been recently reported. This case report demonstrates the effectiveness of VR-based intervention in improving the gait of a female patient in her 90s with a femoral neck fracture who had difficulty in independent gait postoperatively due to trunk dysfunction. The patient had undergone bipolar hip hemiarthroplasty for a right femoral neck fracture sustained via a fall at home. Standard physical therapy, including range of motion exercises, resistance training, and gait training, was commenced gradually the day after surgery. An improvement in lower extremity pain was reported at the two-month follow-up visit but without any improvement in the gait ability. Trunk flexion was observed during gait, and the patient had difficulty in independent gait and walking without upper limb support. Withdrawal and reversal designs (BAB) were employed, and each period lasted one week. Standard physiotherapy supplemented with trunk reach training in a seated position using VR equipment was commenced subsequently. An improvement in the maximum anterior pelvic tilt angle and sitting and standing postures, increased hip extension range of motion and step length during gait, and decreased gait speed were observed during the intervention phase. These results highlight the importance of physiotherapy interventions targeting the trunk muscle and the effectiveness of VR-guided trunk training in patients with femoral neck fractures.

Effectiveness of Immersive Virtual Reality-Based Hand Rehabilitation Games for Improving Hand Motor Functions in Subacute Stroke Patients

Stroke rehabilitation faces challenges in attaining enduring improvements in hand motor function and is frequently constrained by interventional limitations. This research aims to present an innovative approach to the integration of cognitive engagement within visual feedback incorporated into fully immersive virtual reality (VR) based games to achieve enduring improvements. These innovative aspects of interaction provide more functional advantages beyond motivation to efficiently execute repeatedly hand motor tasks. The effectiveness of virtual reality games incorporated with innovative aspects has been investigated for improvements in hand motor functions. A randomized controlled trial was conducted, a total of (n=56) subacute stroke patients were assessed for eligibility and (n=52) patients fulfilled the inclusion criteria. (n=26) patients were assigned to the experimental group and (n=26) patients were assigned to the control group. VR intervention involves four VR based games, developed based on hand movements including flexion/extension, close/open, supination/pronation and pinch. All patients got therapy of 24 sessions, lasting 4 days/week for a total of 6 weeks. Five clinical outcome measures were Fugl- Meyer Assessment-Upper Extremity, Action Research Arm Test, Box and Block Test, Modified Barthel Index, and Stroke-Specific Quality of Life were assessed to evaluate patients' performance. Results revealed that after therapy there was significant improvement between the groups (p<0.05) and within groups (p<0.05) in all assessment weeks in all clinical outcome measures however, improvement was observed significantly greater in the experimental group due to fully immersive VR-based games. Results indicated that cognitive engagement within visual feedback incorporated in VR-based hand games effectively improved hand motor functions.

The efficacy of virtual reality for upper limb rehabilitation in stroke patients: a systematic review and meta-analysis

BACKGROUND

Stroke frequently gives rise to incapacitating motor impairments in the upper limb. Virtual reality (VR) rehabilitation has exhibited potential for augmenting upper extremity recovery; nonetheless, the optimal techniques for such interventions remain a topic of uncertainty. The present systematic review and meta-analysis were undertaken to comprehensively compare VR-based rehabilitation with conventional occupational therapy across a spectrum of immersion levels and outcome domains.

METHODS

A systematic search was conducted in PubMed, IEEE, Scopus, Web of Science, and PsycNET databases to identify randomized controlled trials about upper limb rehabilitation in stroke patients utilizing VR interventions. The search encompassed studies published in the English language up to March 2023. The identified studies were stratified into different categories based on the degree of immersion employed: non-immersive, semi-immersive, and fully-immersive settings. Subsequent meta-analyses were executed to assess the impact of VR interventions on various outcome measures.

RESULTS

Of the 11,834 studies screened, 55 studies with 2142 patients met the predefined inclusion criteria. VR conferred benefits over conventional therapy for upper limb motor function, functional independence, Quality of life, Spasticity, and dexterity. Fully immersive VR showed the greatest gains in gross motor function, while non-immersive approaches enhanced fine dexterity. Interventions exceeding six weeks elicited superior results, and initiating VR within six months post-stroke optimized outcomes.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that adjunctive VR-based rehabilitation enhances upper limb motor recovery across multiple functional domains compared to conventional occupational therapy alone after stroke. Optimal paradigms likely integrate VR's immersive capacity with conventional techniques.

TRIAL REGISTRATION

This systematic review and meta-analysis retrospectively registered in the OSF registry under the identifier [ https://doi.org/10.17605/OSF.IO/YK2RJ ].

Exploring the usability of the virtual reality module LEAF CAFÉ: a qualitative think-aloud study

BACKGROUND

The global healthcare system faces increasing strain from our ageing population, primarily due to the growing prevalence of age-related health conditions such as dementia. While modern healthcare technology offers potential solutions, it frequently lacks user-friendliness for older adults. Virtual Reality (VR) has emerged as a promising tool for diagnosing cognitive impairment, offering innovative solutions where traditional methods may fall short. This study explores older adults' perspectives on the usability of a newly designed VR module for cognitive assessment.

METHODS

During a 100-min session, participants were asked to engage and complete recall and recognition tasks within the VR module (think-aloud approach) and provide feedback upon completion (semi-structured interviews). Audio materials were transcribed for analysis and recordings of the users' interactions with the module were annotated to provide additional context. These combined textual data were analysed using content coding and thematic analysis to identify themes that reflect how participants used the module's features and what features are desirable to support that process better.

RESULTS

Participants (N = 10; Mean age = 73.3, SD = 7.53, range = 65-83 years) perceived the VR module as user-friendly and endorsed its potential as a cognitive screener due to its engaging and immersive nature. Older adults highlighted three key aspects of the module: the usefulness of the platform's ability to offer a comprehensive and reliable evaluation of an individual's cognitive abilities; the need to present concise and relevant content to optimise engagement and use; and the importance of overcoming barriers to support implementation. Suggested game improvements centred on food recognition and adjusting difficulty levels. Barriers to implementation included technology challenges for older adults and concerns about the game's suitability for everyday scenarios. Participants stressed the need for reliable implementation strategies, proposing locations such as libraries and advocating for home-based screening.

CONCLUSION

Continued improvements in accessibility suggest that VR tools could help with diagnosing cognitive impairment in older adults. Using a simulated environment to assess cognitive status might fill the gap between current diagnostic methods, aiding treatment planning and early intervention. However, these findings should be approached cautiously, as more research is needed to fully grasp the potential impact of VR tools in this context.

Current status and clinical perspectives of extended reality for myoelectric prostheses: review

Training with "Extended Reality" or X-Reality (XR) systems can undoubtedly enhance the control of the myoelectric prostheses. However, there is no consensus on which factors improve the efficiency of skill transfer from virtual training to actual prosthesis abilities. This review examines the current status and clinical applications of XR in the field of myoelectric prosthesis training and analyses possible influences on skill migration. We have conducted a thorough search on databases in the field of prostheses using keywords such as extended reality, virtual reality and serious gaming. Our scoping review encompassed relevant applications, control methods, performance evaluation and assessment metrics. Our findings indicate that the implementation of XR technology for myoelectric rehabilitative training on prostheses provides considerable benefits. Additionally, there are numerous standardised methods available for evaluating training effectiveness. Recently, there has been a surge in the number of XR-based training tools for myoelectric prostheses, with an emphasis on user engagement and virtual training evaluation. Insufficient attention has been paid to significant limitations in the behaviour, functionality, and usage patterns of XR and myoelectric prostheses, potentially obstructing the transfer of skills and prospects for clinical application. Improvements are recommended in four critical areas: activities of daily living, training strategies, feedback, and the alignment of the virtual environment with the physical devices.

Virtual Reality for the Rehabilitation of Acquired Cognitive Disorders: A Narrative Review

This review article explores the use of Virtual Reality (VR) technology in cognitive rehabilitation for individuals with neurological conditions, such as stroke, traumatic brain injury, and neurodegenerative diseases. The introduction highlights the challenges posed by cognitive impairments and the limitations of traditional rehabilitation methods. VR is presented as a transformative tool that immerses individuals in interactive environments, offering promising opportunities for enhancing cognitive functions and improving quality of life. This article covers the foundational principles of VR, its applications across different clinical conditions and cognitive domains, and evaluates empirical evidence supporting its efficacy. It also discusses the advantages, limitations, challenges, and ethical considerations in the use of VR for cognitive rehabilitation. This review concludes by exploring future developments, including advancements in VR technology, the integration of Augmented Reality (AR) and artificial intelligence (AI), and the importance of standardized assessment tools for the objective evaluation of rehabilitation outcomes.

Effects of Nonimmersive Virtual Reality Intervention on Children With Spastic Cerebral Palsy: A Meta-analysis and Systematic Review

ABSTRACT

This review aimed to assess the effectiveness of nonimmersive virtual reality intervention compared with traditional rehabilitation in improving the functions of the upper and lower limbs, balance, and social participation among children with spastic cerebral palsy. We used librarian-designed searches of 10 databases to identify research articles on randomized controlled trials that assessed the effectiveness of nonimmersive virtual reality in intervening spastic cerebral palsy patients up to April 15, 2023. Independent evaluation was conducted by two trained investigators using the evaluation criteria of randomized controlled trial quality indicated in the Cochrane Manual of Assessment "risk-of-bias tool." The Physical Therapy Evidence Database scale was used to evaluate the method and quality of the literature. Twenty-one research articles involving 779 patients with spastic cerebral palsy were included. Significant differences between the nonimmersive virtual reality rehabilitation and traditional rehabilitation groups were observed in all indicators, except for the Jebsen-Taylor Hand Function Test. Nonimmersive virtual reality intervention is effective in improving the function of the lower extremity, balance, and social participation in children with spastic cerebral palsy, but its effect on upper limb function is still controversial.

The Extent of Evidence Supporting the Effectiveness of Extended Reality Telerehabilitation on Different Qualitative and Quantitative Outcomes in Stroke Survivors: A Systematic Review

Objective: To present the extent of evidence concerning the effectiveness of extended reality telerehabilitation and patients' experiences of using different types of virtual reality exercises at home. Methods: We included studies on virtual reality and augmented reality telerehabilitation published in English. Systematic searches were undertaken in PubMed, Web of Sciences, Medline, Embase, CINAHL, and PEDro, with no date limitations. We included only RCTs and qualitative studies exploring patients' experiences. Methodological quality was assessed using the Cochrane Risk of Bias assessment tool for quantitative papers and the CASP scale for qualitative studies. All results are presented narratively. Results: Thirteen studies, nine quantitative and four qualitative, were included, with one qualitative and seven quantitative having a high risk of bias. All studies reported that extended reality-based telerehabilitation may be effective compared to conventional exercises or other extended reality exercises. Seven quantitative studies focused on upper limb function. Qualitative papers suggested that VR exercises were perceived as feasible by patients. Conclusions: The literature suggests VR home exercises are feasible and potentially effective for patients after a stroke in the upper limb. Further high-quality studies are needed to examine the effectiveness of XR exercises early adoption on different qualitative and quantitative outcomes. Registration number: (CRD42022384356).

Is Balance Training Using Biofeedback Effective in the Prophylaxis of Falls in Women over the Age of 65?

The paper aims to investigate the usefulness of training in improving mobility and reducing the risk of falls of patients with osteoarthritis by using a force plate and virtual reality as rehabilitation tools. The study involved 72 women randomly divided into two equal groups: the force plate training group, which underwent virtual balance training with visual motor feedback, and the gym training group, which received conventional balance training only. The functional balance assessment was performed before and after the rehabilitation by computerized posturography in a relaxed upright position with open and closed eyes, with visual motor feedback. In the FPT group in the feedback measurement, the mean radius of sways was 30% smaller after rehabilitation (p < 0.00002); the feedback coordination coefficient was more than 10% bigger after rehabilitation (p < 0.001) and reached 92%, which is excellent for elderly people. Total stagnation and stumbling reported by patients decreased after rehabilitation compared to the first examination. Both tested forms of training can contribute to reducing the risk of falls. However, a more significant improvement was obtained in the force plate training group perhaps because the physical effort on a force plate trains the precise movements needed to reposition the centre of gravity without generating excessive inertia forces responsible for loss of balance and falls. Perhaps the most desirable method of intervention is to train a person's ability to perform slow but definite body movements.

Can specific virtual reality combined with conventional rehabilitation improve poststroke hand motor function? A randomized clinical trial

TRIAL OBJECTIVE

To verify whether conventional rehabilitation combined with specific virtual reality is more effective than conventional therapy alone in restoring hand motor function and muscle tone after stroke.

TRIAL DESIGN

This prospective single-blind randomized controlled trial compared conventional rehabilitation based on physiotherapy and occupational therapy (control group) with the combination of conventional rehabilitation and specific virtual reality technology (experimental group). Participants were allocated to these groups in a ratio of 1:1. The conventional rehabilitation therapists were blinded to the study, but neither the participants nor the therapist who applied the virtual reality-based therapy could be blinded to the intervention.

PARTICIPANTS

Forty-six patients (43 of whom completed the intervention period and follow-up evaluation) were recruited from the Neurology and Rehabilitation units of the Hospital General Universitario of Talavera de la Reina, Spain.

INTERVENTION

Each participant completed 15 treatment sessions lasting 150 min/session; the sessions took place five consecutive days/week over the course of three weeks. The experimental group received conventional upper-limb strength and motor training (100 min/session) combined with specific virtual reality technology devices (50 min/session); the control group received only conventional training (150 min/session).

RESULTS

As measured by the Ashworth Scale, a decrease in wrist muscle tone was observed in both groups (control and experimental), with a notably larger decrease in the experimental group (baseline mean/postintervention mean: 1.22/0.39; difference between baseline and follow-up: 0.78; 95% confidence interval: 0.38-1.18; effect size = 0.206). Fugl-Meyer Assessment scores were observed to increase in both groups, with a notably larger increase in the experimental group (total motor function: effect size = 0.300; mean: - 35.5; 95% confidence interval: - 38.9 to - 32.0; wrist: effect size = 0.290; mean: - 5.6; 95% confidence interval: - 6.4 to - 4.8; hand: effect size = 0.299; mean: - -8.9; 95% confidence interval: - 10.1 to - 7.6). On the Action Research Arm Test, the experimental group quadrupled its score after the combined intervention (effect size = 0.321; mean: - 32.8; 95% confidence interval: - 40.1 to - 25.5).

CONCLUSION

The outcomes of the study suggest that conventional rehabilitation combined with a specific virtual reality technology system can be more effective than conventional programs alone in improving hand motor function and voluntary movement and in normalizing muscle tone in subacute stroke patients. With combined treatment, hand and wrist functionality and motion increase; resistance to movement (spasticity) decreases and remains at a reduced level.

TRIALS REGISTRY

International Clinical Trials Registry Platform: ISRCTN27760662 (15/06/2020; retrospectively registered).

Effects of virtual reality-based intervention on depression in stroke patients: a meta-analysis

As one of the most common neuropsychiatric complications after stroke, post-stroke depression can significantly affect the initiative of rehabilitation exercise and the rehabilitation of neurological function of patients. Virtual reality (VR) has been widely used in health-related fields in recent years. There is some evidence that VR-based interventions have benefits for depression. The aim of this study was to assess the effectiveness of VR-based intervention on depression in stroke patients. A total of 752 patients with stroke from 11 randomized controlled trials (RCTs) studies were included in this meta-analysis and the studies derived from seven electronic databases searched from database inception to August 2021. Different tools were used to measure depression. For continuous results, the standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated to synthesize the effects. We assessed the risk of bias by using the Cochrane Collaboration criteria. The results showed that compared to the control group, VR-based interventions significantly decreased the depression scale score (SMD =  - 0.75, 95% CI - 1.35, - 0.15). The meta-analysis indicated that VR-based intervention had a moderate effect on depression in stroke patients compared to control group. There was no evidence of potential publication bias as assessed by visual inspection of funnel plots in Egger and Begg tests. Substantial heterogeneity between studies was observed, meta-regression analysis showed that mean age might be the source of heterogeneity.

A Pilot Study to Assess Visual Vertigo in People with Persistent Postural-Perceptual Dizziness with a New Computer-Based Tool

BACKGROUND

Visual vertigo (VV) is a common symptom in people with persistent postural-perceptual dizziness (PPPD). Few subjective scales are validated for assessing the intensity of VV, yet these scales are limited by recall bias, as they require individuals to rate their symptoms from memory. The computer-Visual Vertigo Analogue Scale (c-VVAS) was developed by adapting five scenarios from the original paper-VVAS (p-VVAS) into 30 s video clips. The aim of this pilot study was to develop and test a computerized video-based tool for the assessment of visual vertigo in people with PPPD.

METHODS

PPPD participants (n = 8) and age- and sex-matched controls (n = 8) completed the traditional p-VVAS and the c-VVAS. A questionnaire about their experiences using the c-VVAS was completed by all participants.

RESULTS

There was a significant difference between the c-VVAS scores from the PPPD and the control group (Mann-Whitney, p < 0.05). The correlation between the total c-VVAS scores and the total c-VVAS scores was not significant (r = 0.668, p = 0.07). The study showed a high acceptance rate of the c-VVAS by participants (mean = 91.74%).

CONCLUSION

This pilot study found that the c-VVAS can distinguish PPPD subjects from healthy controls and that it was well-received by all participants.

Functional Living Skills in Patients with Major Neurocognitive Disorder Due to Degenerative or Non-Degenerative Conditions: Effectiveness of a Non-Immersive Virtual Reality Training

Virtual reality has gained attention as an effective tool for cognitive, motor, and daily activity rehabilitation in patients with major neurocognitive disorder (M-NCD). The first objective of this study was to check for differences between M-NCD caused by degenerative and non-degenerative conditions (DC and NDC, respectively) in terms of relearning four functional living skills (FLSs), by means of a non-immersive virtual reality training (VRT). The second purpose was to verify whether spontaneous transfer from the virtual environment to the real environment occurred. Four FLS apps were developed in our institute (Information, Suitcase, Medicine, and Supermarket). A nonrandomized interventional study was carried out, comparing experimental and control groups (EG and CG, respectively). The study included three phases: in vivo test at T1; VRT at T2 only for EG; in vivo test at T3. During the in vivo test, the four FLSs were assessed in their natural environments. Both EG-DC and EG-NDC significantly improved in all of the VRT variable scores (the EG-NDC group seemed to show better outcomes than the EG-DC group). Moderate-to-high satisfaction with the VRT was reported. EG-DC and EG-NDC also enhanced their performances in the in vivo test. No statistically significant differences between them were found. CG-DC and CG-NDC improved only in the execution time of Information in the in vivo test. These findings confirm the ecological validity of VRT for FLSs.

The Effect of Non-Immersive Virtual Reality Exergames versus Traditional Physiotherapy in Parkinson's Disease Older Patients: Preliminary Results from a Randomized-Controlled Trial

(1) Background: Parkinson's disease (PD) is one of the most frequent causes of disability among older people. Recently, virtual reality and exergaming have been emerged as promising tools for gait and balance rehabilitation in PD patients. Our purpose is to evaluate an innovative treatment for older patients with PD, based on non-immersive virtual reality exergames, improving gait and balance and reducing falling risk. (2) Methods: Thirty PD patients were recruited and randomly divided into two groups, to receive a traditional rehabilitation (CG) or a technological rehabilitation (TG). (3) Results: A statistical improvement of balance at the end of treatments was observed in both groups (CG: 12.4 ± 0.7 vs. 13.5 ± 0.8, p = 0.017; TG: 13.8 ± 0.5 vs. 14.7 ± 0.4, p = 0.004), while the overall risk of falling was significantly reduced only in the TG (POMA Total: 24.6 ± 0.9 vs. 25.9 ± 0.7, p = 0.010). The results between groups shows that all POMA scores differ in a statistically significant manner in the TG, emphasizing improvement not only in balance but also in gait characteristics (9.7 ± 0.8 vs. 11.4 ± 0.2, p = 0.003). Moreover, TG also improves the psychological sphere, measured thorough MSC-(17.1 ± 0.4 vs. 16.5 ± 0.4, p = 0.034). Although an improvement in FES-I and Gait Speed can be observed, this increase does not turn out to be significant. (4) Conclusions: Results suggest how non-immersive virtual reality exergaming technology offers the opportunity to effectively train cognitive and physical domains at the same time.

Non-Immersive Virtual Reality as an Intervention for Improving Hand Function and Functional Independence in Children With Unilateral Cerebral Palsy: A Feasibility Study

Introduction

Non-immersive virtual reality (NIVR) is emerging as an advantageous intervention in the arena of neurorehabilitation. Promising results have been obtained by the application of NIVR in adults with various chronic neurological conditions such as stroke and Parkinson’s disease, but studies on the use of NIVR in children with unilateral cerebral palsy (CP) are limited.

Materials and methods

This preliminary study included 10 school-aged participants with unilateral CP who were allocated into experimental and control groups. In accordance with the allocation ratio of 1:1, there were five participants in each group. During six weeks of intervention, children in the experimental group received NIVR intervention in addition to conventional physiotherapy, while those in the control group received only conventional physiotherapy, with a goal to improve hand function and functional independence. Nine-hole peg test (9HPT), box and block test (BBT), ABILHAND kids, and self-care section of functional independence measure for children (WeeFIM) were used as outcome measures.

Results

There was significant improvement in all outcome measures in both groups. However, the improvement in the hand function and functional independence was significantly more in the experimental group than in the control group.

Conclusion

It can be concluded that NIVR intervention in the management of children with unilateral CP seems to be feasible and useful. Further research with a larger sample size must be undertaken to reinforce these preliminary findings.

Effect of virtual reality technology as intervention for people with kinesiophobia: A meta-analysis of randomised controlled trials

AIMS AND OBJECTIVE

To explore the effectiveness of Virtual Reality Technology in reducing kinesiophobia in people.

BACKGROUND

Kinesiophobia is an important psychosocial factor affecting the pain experience and has a significant negative impact on rehabilitation. Virtual reality technology has been widely used in the treatment of phobias, mental disorders and anxiety disorders. However, the effect of virtual reality technology on people with kinesiophobia has been reported with inconsistent results.

DESIGN

A meta-analysis of randomised controlled trials.

METHODS

This study systematically searched PubMed, Web of Science, PsycINFO, CINAHL, Embase, Cochrane Library, Medline, Scopus and four Chinese databases. The standardised mean difference (SMD) was calculated using random-effects models, and the Cochrane Collaboration's tool was used to assess the risk of bias in each study. The PRISMA 2020 checklist provided by the EQUATOR network was used.

RESULTS

Eleven randomised controlled trials involving a total of 488 subjects were included. Meta-analysis showed the effect sizes of virtual reality intervention on kinesiophobia (SMD = -0.53, 95% CI [-0.90, -0.17], p = .004). Virtual reality intervention was more effective in reducing kinesiophobia in people with chronic low back pain (SMD = -1.00, 95% CI [-1.71, -0.29], p = .006). Compared with fully immersive virtual reality (SMD = -0.29, 95% CI [-0.62, 0.05], p = 0.09), non-immersive virtual reality was more effective in reducing kinesiophobia (SMD = -0.66, 95% CI [-1.24, -0.09], p = 0.02). Compared with virtual reality intervention alone (SMD = -0.35, 95% CI [-1.40, 0.71], p = 0.52), virtual reality combined with exercise was more effective in reducing kinesiophobia (SMD = -0.59, 95% CI [-0.95, -0.22], p = 0.002).

CONCLUSIONS

Virtual reality technology has the potential to reduce the degree of kinesiophobia in people. In addition, virtual reality technology was more effective in people with chronic low back pain; non-immersive virtual reality was more effective in reducing kinesiophobia; and virtual reality technology combined with exercise was more effective in reducing kinesiophobia than virtual reality intervention alone. Clinical nursing staff should be encouraged to use virtual reality to speed up patient recovery. However, to achieve immersion and apply this technology to different diseases, more studies are required to provide clearer suggestions.

RELEVANCE TO CLINICAL PRACTICE

This study suggests that healthcare staff should pay attention to kinesiophobia, and early identification and intervention of kinesiophobia can help patients recover their health and improve the quality of nursing.

Dancing With Parkinson's Disease: The SI-ROBOTICS Study Protocol

Introduction: Parkinson's disease (PD) is one of the most frequent causes of disability among older people, characterized by motor disorders, rigidity, and balance problems. Recently, dance has started to be considered an effective exercise for people with PD. In particular, Irish dancing, along with tango and different forms of modern dance, may be a valid strategy to motivate people with PD to perform physical activity. The present protocol aims to implement and evaluate a rehabilitation program based on a new system called “SI-ROBOTICS,” composed of multiple technological components, such as a social robotic platform embedded with an artificial vision setting, a dance-based game, environmental and wearable sensors, and an advanced AI reasoner module.

Methods and Analysis: For this study, 20 patients with PD will be recruited. Sixteen therapy sessions of 50 min will be conducted (two training sessions per week, for 8 weeks), involving two patients at a time. Evaluation will be primarily focused on the acceptability of the SI-ROBOTICS system. Moreover, the analysis of the impact on the patients' functional status, gait, balance, fear of falling, cardio-respiratory performance, motor symptoms related to PD, and quality of life, will be considered as secondary outcomes. The trial will start in November 2021 and is expected to end by April 2022.

Discussions: The study aims to propose and evaluate a new approach in PD rehabilitation, focused on the use of Irish dancing, together with a new technological system focused on helping the patient perform the dance steps and on collecting kinematic and performance parameters used both by the physiotherapist (for the evaluation and planning of the subsequent sessions) and by the system (to outline the levels of difficulty of the exercise).

Ethics and Dissemination: The study was approved by the Ethics Committee of the IRCCS INRCA. It was recorded in ClinicalTrials.gov on the number NCT05005208. The study findings will be used for publication in peer-reviewed scientific journals and presentations in scientific meetings.

User-Centered Virtual Environment for Post-Stroke Motor Rehabilitation

The use of Virtual Reality in the rehabilitation of lost or diminished functions after a stroke has been shown to be an innovative means in motor recovery. However, there are still several design challenges to increment the efficiency of these systems. This paper presents the development and evaluation of a non-immersive 3D virtual environment for post-stroke rehabilitation of elbow flexion-extension movements, which considers the therapist as a direct user and the patient as a secondary user. The development of virtual environment was supported by the criteria of a team of specialists in physical and occupational therapy, following the philosophy of User-Centered Design through three iterations, and incorporating tasks based on the Activities of Daily Living of the Barthel scale. Tests were carried out with healthy users and a patient with a diagnosis of stroke, using the SUS test and a flow status questionnaire respectively. Average satisfaction of user group without diagnosis was 79.6 out of 100 points. On the other hand, according to mean values observed with the patient, dimensions of control sense (6.33) and positive emotional experience (6.66) reflect an "optimal" experience, which indicates an enjoyment of virtual tasks de-spite the effort made to fulfill them.

Does spatial perspective in virtual reality affect imitation accuracy in stroke patients?

Imitation is an important daily activity involved in social interactions, motor learning, and is commonly used for rehabilitation after stroke. Moreover, deficits in imitation of novel movements commonly occur after left hemisphere stroke (LCVA) in the syndrome of limb apraxia. In the current study, we used a novel virtual reality (VR) imitation paradigm to assess two factors that have remained underexplored in novel movement imitation: the imitation of complex, dynamic full-arm movements, and the effect of spatial perspective. VR holds promise as a tool for a number of clinical assessments and treatments, but has very rarely been studied in the context of imitation or diagnosis of apraxia. Thirty participants (18 with LCVA and 12 age- and education-matched controls) wore a VR headset and observed and imitated an instructor avatar demonstrating arm movements. Three spatial perspectives were examined within-subjects: first-person, third-person mirror, and third-person anatomical. Movements of the ipsilesional (left) arm were recorded and qualitatively coded for accuracy compared to the instructor avatar. Participants also completed embodiment questionnaires, a measure of limb apraxia (imitation of video-recorded meaningless movements), and three computerized background tasks that were hypothesized to evoke some of the same processing requirements of each of the three perspective conditions: a block-matching task, a block-mirroring task, and a mental rotation task. Imitation accuracy was highest in the first-person perspective, consistent with predictions, but did not differ between third-person mirror and anatomical. Surprisingly, patients and controls performed similarly on the imitation task for all spatial perspectives, with overall modest accuracy in both groups, and both patients and controls felt a moderate level of embodiment of their own avatar. Higher imitation accuracy related to quicker block-matching reaction times and higher mental rotation accuracy, regardless of perspective, but was unrelated to imitation of video-recorded meaningless movements. In sum, virtual reality provides advantages in terms of experimental manipulation and control but may present challenges in detecting clinical imitation deficits (limb apraxia).

The Neuromatrix Theory of Pain and Transactional Theory of Stress and Coping: Improving Understanding of Pain Catastrophizing in Individuals With ACL Reconstruction and Knee Osteoarthritis

Individuals with anterior cruciate ligament reconstruction and early knee osteoarthritis symptoms commonly exhibit psychological impairments, such as pain catastrophizing. Pain catastrophizing is a negative cognitive–affective response to anticipated or actual pain and has been linked to greater pain intensity and decreased function in this population. However, an examination of the neuromatrix theory of pain and the transactional theory of stress and coping may help to explain the development and consequences of pain catastrophizing in individuals with anterior cruciate ligament reconstruction and early knee osteoarthritis symptoms. Exploration of these theoretical models will help clinicians better understand the impact of pain catastrophizing on post-injury outcomes, as well as help to identify intervention strategies to address maladaptive psychological responses and improve outcomes for individuals with anterior cruciate ligament reconstruction and early knee osteoarthritis symptoms.

Virtual and augmented reality applications to improve older adults' quality of life: A systematic mapping review and future directions

Objective

The use of virtual reality and augmented reality to improve older adults' quality of life has rapidly increased in recent years. This systematic mapping review aimed to provide a comprehensive overview of existing research that identifies and classifies current virtual reality and augmented reality applications that enhance the quality of life of older adults to increase the understanding of the impact of these technologies.

Methods

To reach this objective, a systematic mapping review was conducted of the studies published between 2009 and 2020 in major scientific databases, such as IEEE Xplore, Web of Science, Scopus, and PubMed. A total of 57 studies were analyzed and classified into four main quality of life domains: physical, cognitive, psychological, and social well-being.

Results

The findings showed that virtual reality and augmented reality have found their places in many quality of life studies of older adults. Although virtual reality and augmented reality applications are notably growing in the physical and cognitive well-being domains in training and rehabilitation settings, they are still in the early stages of development in psychological and social well-being research as well as healthcare settings. Our findings also revealed that virtual reality games, particularly motion-based exergames, and 3D augmented reality systems are the most common virtual reality and augmented reality types among the reviewed studies. Moreover, balance and attention were the most prevalent physical and cognitive functions when using motion-based and immersive virtual reality exergames and augmented reality systems and games, respectively, while confidence and interaction were the most dominant psychological and social functions.

Conclusion

This mapping review provides a comprehensive overview of potential areas for further research in this field, thereby assisting researchers, technologists, and health practitioners in expanding this field of research.

Towards Consensus on Good Practices for the Use of New Technologies for Intervention and Support in Developmental Dyslexia: A Delphi Study Conducted among Italian Specialized Professionals

The use of new technologies for intervention in developmental dyslexia is steadily growing. In order to better understand the needs, the expectations, and the attitudes of Italian expert health professionals concerning such technologies, a national survey was conducted applying the Delphi methodology. Ad-hoc questionnaires were sent out to a group of eighteen experts over three successive rounds, and anonymously collected responses were aggregated and shared with the group after each round, aiming to reach a consensus on the proposed response. The goal was to define a series of statements that could form the basis for international "good practices" in the use of technologies for intervention to support dyslexia in children and adolescents. In the first round, the experts' general opinions were collected with both multiple choice and open questions, and in the second round consensus was assessed on a series of statements based on the first replies. The cut-off of 75% consensus on each statement was reached after three rounds. Fifteen experts completed all the rounds of the process, and a final version of the statements regarding good practice in the use of technologies for dyslexia could be defined.

Virtual Reality Applications in Medicine During the COVID-19 Pandemic: Systematic Review (Preprint)

Background

Virtual reality can play an important role during the COVID-19 pandemic in the health care sector. This technology has the potential to supplement the traditional in-hospital medical training and treatment, and may increase access to training and therapies in various health care settings.

Objective

This systematic review aimed to describe the literature on health care–targeted virtual reality applications during the COVID-19 crisis.

Methods

We conducted a systematic search of the literature on the PsycINFO, Web of Science, and MEDLINE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The search string was as follows: “[(virtual reality)] AND [(COVID-19) OR (coronavirus) OR (SARS-CoV-2) OR (healthcare)].” Papers published in English after December 2019 in peer-reviewed journals were selected and subjected to the inclusion and exclusion criteria. We used the Mixed Methods Appraisal Tool to assess the quality of studies and the risk of bias.

Results

Thirty-nine studies met the inclusion criteria. Seventeen studies showed the usefulness of virtual reality during the COVID-19 crisis for reducing stress, anxiety, depression, and pain, and promoting physical activity. Twenty-two studies revealed that virtual reality was a helpful learning and training tool during the COVID-19 crisis in several areas, including emergency medicine, nursing, and pediatrics. This technology was also used as an educational tool for increasing public understanding of the COVID-19 pandemic. Different levels of immersion (ie, immersive and desktop virtual reality), types of head-mounted displays (ie, PC-based, mobile, and standalone), and content (ie, 360° videos and photos, virtual environments, virtual reality video games, and embodied virtual agents) have been successfully used. Virtual reality was helpful in both face-to-face and remote trials.

Conclusions

Virtual reality has been applied frequently in medicine during the COVID-19 pandemic, with positive effects for treating several health conditions and for medical education and training. Some barriers need to be overcome for the broader adoption of virtual reality in the health care panorama.

Trial Registration

International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) INPLASY202190108; https://inplasy.com/inplasy-2021-9-0108/

Serious Game Design and Clinical Improvement in Physical Rehabilitation: Systematic Review

Background

Serious video games have now been used and assessed in clinical protocols, with several studies reporting patient improvement and engagement with this type of therapy. Even though some literature reviews have approached this topic from a game perspective and presented a broad overview of the types of video games that have been used in this context, there is still a need to better understand how different game characteristics and development strategies might impact and relate to clinical outcomes.

Objective

This review assessed the relationship between the characteristics of serious games (SGs) and their relationship with the clinical outcomes of studies that use this type of therapy in motor impairment rehabilitation of patients with stroke, multiple sclerosis, or cerebral palsy. The purpose was to take a closer look at video game design features described in the literature (game genre [GG], game nature [GN], and game development strategy [GDS]) and assess how they may contribute toward improving health outcomes. Additionally, this review attempted to bring together medical and game development perspectives to facilitate communication between clinicians and game developers, therefore easing the process of choosing the video games to be used for physical rehabilitation.

Methods

We analyzed the main features of SG design to obtain significant clinical outcomes when applied to physical rehabilitation of patients recovering from motor impairments resulting from stroke, multiple sclerosis, and cerebral palsy. We implemented a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) database-adjusted electronic search strategy for the PubMed, IEEE Xplore, and Cochrane databases.

Results

We screened 623 related papers from 2010-2021 and identified 12 that presented results compatible with our inclusion criteria. A total of 512 participants with stroke (8 studies, 417 participants), cerebral palsy (1 study, 8 participants), and multiple sclerosis (2 studies, 46 participants) were included; 1 study targeting the elderly (41 participants) was also included. All studies assessed motor, sensory, and functional functions, while some also measured general health outcomes. Interventions with games were used for upper-limb motor rehabilitation. Of the 12 studies, 8 presented significant improvements in at least one clinical measurement, of which 6 presented games from the casual GG, 1 combined the casual, simulation, and exergaming GGs, and 2 combined the sports and simulation GGs.

Conclusions

Of the possible combinations of game design features (GG, GN, and GDS) described, custom-made casual games that resort to the first-person perspective, do not feature a visible player character, are played in single-player mode, and use nonimmersive virtual reality attain the best results in terms of positive clinical outcomes. In addition, the use of custom-made games versus commercial off-the-shelf games tends to give better clinical results, although the latter are perceived as more motivating and engaging.

Exergames to Prevent the Secondary Functional Deterioration of Older Adults during Hospitalization and Isolation Periods during the COVID-19 Pandemic

The COVID-19 pandemic is having an intense impact on the functional capacity of older adults, making them more vulnerable to frailty and dependency. The development of preventive and rehabilitative measures which counteract the consequences of confinement or hospitalization is an urgent need. Exergaming can promote physical activity, prevent falls, and maintain functional and cognitive capacity. However, although the use of exergames in health programs for the elderly is promising, their widespread use should not be considered without the supervision of a social health professional. Therefore, the objective of this work was to evaluate and analyze three video game consoles (Nintendo Wii®, Xbox-Kinect® and Play Station 4®) and 26 commercial exergames with the aim of identifying their usefulness for the prevention of functional deterioration. Three occupational therapists analyzed the data independently, and subsequently agreed on the results. The examination of the commercial consoles met three criteria: components, interaction channels and the type of the exergame. Each exergame was analyzed taking into account its ability to train postural control, balance, upper limb functionality and cognitive function. The results of the evaluation showed that exergames contain game activities that can be part of the rehabilitative treatment aimed at the prevention of the functional impairment of older people affected by COVID.

Effects of Semi-Immersive Virtual Reality-Based Cognitive Training Combined with Locomotor Activity on Cognitive Function and Gait Ability in Community-Dwelling Older Adults

This study aimed to investigate the effects of semi-immersive virtual reality-based cognitive training (VRCT) combined with locomotor activity on cognitive function, balance, and gait ability in older adults. Eighteen community-dwelling older adults participated in this study. Subjects who met the selection criteria were assigned to an experimental group (n = 9) and a control group (n = 9). The experimental group received VRCT combined with locomotor activity for 30 min a day, three times a week, for 6 weeks. The control group received tabletop activity-based cognitive training for the same amount of time. Before and after the training, the Korean Mini-Mental State Examination (K-MMSE), Trail Making Test (TMT; A and B), and Digit Span Test (DST; forward and backward) were used to evaluate cognitive function; and the Timed Up and Go (TUG) test and 10-m Walking Test (10MWT) were used to evaluate the improvement in the balance and gait ability parameters. After the intervention, the experimental group showed a significantly greater improvement in the TMT-A (p = 0.045) and DST-backward (p = 0.012) scores compared with the control group. Regarding the gait ability variable, the experimental group showed a significant improvement in the 10MWT test (p = 0.001). This study confirmed that semi-immersive VRCT combined with locomotor activity is useful for improving cognitive function and gait ability in older adults. Therefore, VRCT combined with locomotor activity can be used as a simultaneous intervention for cognitive rehabilitation and functional capacity improvement in older adults.

Brain-Computer Interfaces Systems for Upper and Lower Limb Rehabilitation: A Systematic Review

In recent years, various studies have demonstrated the potential of electroencephalographic (EEG) signals for the development of brain-computer interfaces (BCIs) in the rehabilitation of human limbs. This article is a systematic review of the state of the art and opportunities in the development of BCIs for the rehabilitation of upper and lower limbs of the human body. The systematic review was conducted in databases considering using EEG signals, interface proposals to rehabilitate upper/lower limbs using motor intention or movement assistance and utilizing virtual environments in feedback. Studies that did not specify which processing system was used were excluded. Analyses of the design processing or reviews were excluded as well. It was identified that 11 corresponded to applications to rehabilitate upper limbs, six to lower limbs, and one to both. Likewise, six combined visual/auditory feedback, two haptic/visual, and two visual/auditory/haptic. In addition, four had fully immersive virtual reality (VR), three semi-immersive VR, and 11 non-immersive VR. In summary, the studies have demonstrated that using EEG signals, and user feedback offer benefits including cost, effectiveness, better training, user motivation and there is a need to continue developing interfaces that are accessible to users, and that integrate feedback techniques.

Effects of Specific Virtual Reality-Based Therapy for the Rehabilitation of the Upper Limb Motor Function Post-Ictus: Randomized Controlled Trial

This research analyzed the combined effect of conventional treatment and virtual reality exposure therapy on the motor function of the upper extremities in people with stroke. We designed a randomized controlled trial set in the rehabilitation and neurology departments of a hospital (Talavera de la Reina, Spain). The subjects included 43 participants, all randomized into experimental (conventional treatment + virtual reality exposure therapy) and control group (conventional treatment).; The main measures were Fugl-Meyer Assessment for upper extremity, Modified Ashworth Scale, and Stroke Impact Scale 3.0. The results included 23 patients in the experimental (62.6 ± 13.5 years) and 20 in the control group (63.6 ± 12.2 years) who completed the study. After the intervention, muscle tone diminished in both groups, more so in the experimental group (mean baseline/post-intervention: from 1.30 to 0.60; η² = 0.237; p = 0.001). Difficulties in performing functional activities that implicate the upper limb also diminished. Regarding the global recovery from stroke, both groups improved scores, but the experimental group scored significantly higher than the controls (mean baseline/post-intervention: from 28.7 to 86.5; η² = 0.633; p = 0.000). In conclusion, conventional rehabilitation combined with specific virtual reality seems to be more efficacious than conventional physiotherapy and occupational therapy alone in improving motor function of the upper extremities and the autonomy of survivors of stroke in activities of daily living.

Virtual Reality in Neurorehabilitation: An Umbrella Review of Meta-Analyses

Neurological disorders are a leading cause of death and disability worldwide. Can virtual reality (VR) based intervention, a novel technology-driven change of paradigm in rehabilitation, reduce impairments, activity limitations, and participation restrictions? This question is directly addressed here for the first time using an umbrella review that assessed the effectiveness and quality of evidence of VR interventions in the physical and cognitive rehabilitation of patients with stroke, traumatic brain injury and cerebral palsy, identified factors that can enhance rehabilitation outcomes and addressed safety concerns. Forty-one meta-analyses were included. The data synthesis found mostly low- or very low-quality evidence that supports the effectiveness of VR interventions. Only a limited number of comparisons were rated as having moderate and high quality of evidence, but overall, results highlight potential benefits of VR for improving the ambulation function of children with cerebral palsy, mobility, balance, upper limb function, and body structure/function and activity of people with stroke, and upper limb function of people with acquired brain injury. Customization of VR systems is one important factor linked with improved outcomes. Most studies do not address safety concerns, as only nine reviews reported adverse effects. The results provide critical recommendations for the design and implementation of future VR programs, trials and systematic reviews, including the need for high quality randomized controlled trials to test principles and mechanisms, in primary studies and in meta-analyses, in order to formulate evidence-based guidelines for designing VR-based rehabilitation interventions.

Impact of Multidisciplinary Stroke Post-Acute Care on Cost and Functional Status: A Prospective Study Based on Propensity Score Matching

Few papers discuss how the economic burden of patients with stroke receiving rehabilitation courses is related to post-acute care (PAC) programs. This is the first study to explore the economic burden of stroke patients receiving PAC rehabilitation and to evaluate the impact of multidisciplinary PAC programs on cost and functional status simultaneously. A total of 910 patients with stroke between March 2014 and October 2018 were separated into a PAC group (at two medical centers) and a non-PAC group (at three regional hospitals and one district hospital) by using propensity score matching (1:1). A cost-illness approach was employed to identify the cost categories for analysis in this study according to various perspectives. Total direct medical cost in the per-diem-based PAC cohort was statistically lower than that in the fee-for-service-based non-PAC cohort (p < 0.001) and annual per-patient economic burden of stroke patients receiving PAC rehabilitation is approximately US $354.3 million (in 2019, NT $30.5 = US $1). Additionally, the PAC cohort had statistical improvement in functional status vis-à-vis the non-PAC cohort and total score of each functional status before rehabilitation and was also statistically significant with its total score after one-year rehabilitation training (p < 0.001). Early stroke rehabilitation is important for restoring health, confidence, and safe-care abilities in these patients. Compared to the current stroke rehabilitation system, PAC rehabilitation shortened the waiting time for transfer to the rehabilitation ward and it was indicated as an efficient policy for treatment of stroke in saving medical cost and improving functional status.

Virtual Reality in the Assessment, Understanding and Treatment of Mental Health Disorders

Computer scientists usually describe virtual reality (VR) as a set of fancy hardware and software technologies. However, psychology and neuroscience are starting to consider VR as the most advanced form of human-computer interaction allowing individuals to act, communicate and become present in a computer-generated environment. In this view, the feeling of "being there" experienced during a VR experience can become a powerful tool for personal change: it offers a dynamic and social world where individuals can live and share a specific experience. For this reason, the use of VR in mental health shows promise: different researches support its clinical efficacy for conditions including anxiety disorders, stress-related disorders, obesity and eating disorders, pain management, addiction and schizophrenia. However, more research is needed to transform the promises of VR in a real clinical tool for mental health. This Special Issue aims to present the most recent advances in the mental health applications of VR, as well as their implications for future patient care.

Could Virtual Reality play a role in the rehabilitation after COVID-19 infection?

Post-COVID-19 patients, particularly those who needed high care, are expected to have high needs for physical, psychological and cognitive rehabilitation. Yet, the resources needed to provide rehabilitation treatment are expected to be inadequate because healthcare systems faced a shortage of high-quality treatment of these symptoms already before the COVID-19 crisis emerged in patients with comparable needs. In this viewpoint, we discuss the potential of Virtual Reality (VR) administering fast, tailor-made rehabilitation at a distance, and offering a solution for the impending surge of demand for rehabilitation after COVID-19. VR consists of a head-mounted display (HMD) that can bring the user by computer-generated visuals into an immersive, realistic multi-sensory environment. Several studies on VR show its potential for rehabilitation and suggest VR to be beneficial in post-COVID-19. The immersion of VR may increase therapy adherence and may distract the patient from experienced fatigue and anxiety. Barriers still have to be overcome to easily implement VR in healthcare. We argue that embedding VR in virtual care platforms would assist in overcoming these barriers and would stimulate the spread of VR therapy, both for post-COVID-19 patients in the present and possibly for other patients with similar rehabilitation needs in the future.

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.

Effectiveness of Virtual Reality Systems to Improve the Activities of Daily Life in Older People

(1) This review aims to evaluate the effectiveness of treatments with virtual reality systems (VRSs) on the functional autonomy of older adults versus conventional treatment. (3) Methods: Systematic review and meta-analysis. An electronic data search was carried out, following the PRISMA statement, up to February 2020. We combined results from clinical trials using VRSs for the improvement of basic and instrumental activities of daily living. The guidelines of the Cochrane Handbook for Systematic Reviews of Interventions were followed for calculations and risk of bias. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence. (4) Results: The final analysis included 23 studies with a population of 1595 participants. A moderate, but clinically significant, effect was found for basic activities of daily living (BADLs), (Standard Medium Deviation, SMD 0.61; 95% CI: -0.15-1.37; P < 0.001). A small effect was found for instrumental ADLs (Instrumental Activities of daily living, IADLs) (SMD -0.34; 95% CI: -0.82-0.15; P < 0.001). Functional ambulation was the BADL which improved the most (SMD -0.63; 95% CI: -0.86, -0.40; P < 0.001). (5) Conclusion: The use of VRSs is an innovative and feasible technique to support and improve the functional autonomy of community-dwelling older adults. Due to the very low quality of the evidence for our main outcomes, the effects of a VRS on the BADLs and IADLs are uncertain. Clinical trials of a higher methodological quality are necessary to increase the level of knowledge of its actual effectiveness.

A quasi-randomized clinical trial: virtual reality versus proprioceptive neuromuscular facilitation for postmastectomy lymphedema

BACKGROUND

Postmastectomy lymphedema can be considered the main cause of upper extremity functional impairment in patients with breast cancer. Fatigue, pain, and limited range of motion are common symptoms. If left untreated, lymphedema causes cellulitis, which can lead to gangrene in rare cases. This study was carried out to identify and compare the therapeutic advantages of virtual reality-based exercises and proprioceptive neuromuscular facilitation for postmastectomy lymphedema. Thus, a quasi-randomized comparative study of thirty female patients with unilateral postmastectomy lymphedema was conducted. Fifteen patients performed virtual reality-based exercises as well as manual lymphatic drainage, pneumatic compression, and home programs, while the other fifteen patients performed proprioceptive neuromuscular facilitation as well as manual lymphatic drainage, pneumatic compression, and home programs. The excess arm volume between the healthy and affected limbs was estimated before and after eight sessions of treatment for both groups. In addition, the affected limb functional score was calculated. Arm volume was calculated by the truncated cone formula and girth measurements obtained by the circumferential method. The Arabic version of the QuickDASH-9 scale was used to assess extremity function.

RESULTS

The excess arm volume significantly decreased in both the virtual reality group (p = 0.001) and proprioceptive neuromuscular facilitation group (p = 0.005), and there was no significant difference between the two groups (p = 0.902). Age was inversely related to the improvement percentage of the QuickDASH-9 score in the virtual reality group. The functional improvement percentage was statistically significantly different between the two groups (p = 0.045).

CONCLUSION

It can be concluded that both virtual reality and proprioceptive neuromuscular facilitation have a beneficial therapeutic effect on edema in patients with unilateral postmastectomy lymphedema; neither method was found to be superior, except virtual reality was found to be superior to proprioceptive neuromuscular facilitation in motivating patients and providing visual feedback.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04185181 Registered 4 December 2019 - Retrospectively registered.

The Potential of Virtual Reality for Inducing Neuroplasticity in Children with Amblyopia

In recent years, virtual reality (VR) has emerged as a new safe and effective tool for neurorehabilitation of different childhood and adulthood conditions. VR-based therapies can induce cortical reorganization and promote the activation of different neuronal connections over a wide range of ages, leading to contrasted improvements in motor and functional skills. The use of VR for the visual rehabilitation in amblyopia has been investigated in the last years, with the potential of using serious games combining perceptual learning and dichoptic stimulation. This combination of technologies allows the clinician to measure, treat, and control changes in interocular suppression, which is one of the factors leading to cortical alterations in amblyopia. Several clinical researches on this issue have been conducted, showing the potential of promoting visual acuity, contrast sensitivity, and stereopsis improvement. Indeed, several systems have been evaluated for amblyopia treatment including the use of different commercially available types of head mounted displays (HMDs). These HMDs are mostly well tolerated by patients during short exposures and do not cause significant long-term side effects, although their use has been occasionally associated with some visual discomfort and other complications in certain types of subjects. More studies are needed to confirm these promising therapies in controlled randomized clinical trials, with special emphasis on the definition of the most adequate planning for obtaining an effective recovery of the visual and binocular function.