Virtual reality feedback cues for improvement of gait in patients with Parkinson's disease

A Review of Artificial Intelligence-Based Gait Evaluation and Rehabilitation in Parkinson's Disease

Parkinson's disease (PD) is a long-term degenerative disease of the central nervous system that affects both motor and non-motor functions. In most cases, symptoms develop gradually, with non-motor symptoms increasing in frequency as the condition progresses. Tremors, stiffness, slow movements, and difficulty walking are some of the early symptoms. There may be problems with cognition, behavior, sleep, and thinking. Dementia caused by PD becomes more common as the disease progresses. The development of PD is linked to certain sequences of motion that eventually contribute to diminished function. Patients with Parkinson's disease (PWPD) have a sluggish, scattered gait that is accompanied by intermittent freezing of gait (FOG), in which efficient heading briefly pauses. In individuals with severe PD, FOG is a neurological deficit that is related to falls and has an unfavorable impact on the patient's standard of living. Artificial intelligence (AI) and ambient intelligence (AmI) are inextricably linked as intelligence is the ability to gain new information and employ it in novel contexts. The ambience is what accompanies us, while artificial represents something developed by humans. Wearable technologies are being designed to recognize FOG and support patients in the beginning to walk again via periodic cueing. The article proposes a unique automated approach for action description that utilizes AI to carry out a non-intrusive, markerless evaluation in real-time and with full robotics. This computerized method accelerates detection and safeguards from human error. Despite significant improvements brought about by the advent of novel technologies, the available assessment platforms still fail to strike the ideal equilibrium among expenditure, diagnostic precision, velocity, and simplicity. The value of the recommended approach can be seen through a comparison of the gait parameters collected by each of the motion-tracking gadgets.

Designing Virtual Reality Assisted Psychotherapy for Anxiety in Older Adults Living with Parkinson's Disease: Integrating Literature for Scoping

Objective: This review integrates literature to discuss the potential use of virtual reality (VR) in treatment of anxiety in Parkinson's disease (PD) and inform next steps.Methods: A systematic search was performed to identify studies of VR use in PD, using four databases. Data were reported in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR).Results: Thirty-two studies met the inclusion criteria with four VR studies from the same study group directly assessing the effects of anxiety on motor symptoms in PD. Primary studies implementing a VR protocol in PD identified focus areas of understanding and alleviating freezing of gait (FOG), balance training, and cognitive and motor rehabilitation, and informed design considerations.Conclusion: VR in PD studies suggested established feasibility. With appropriate design considerations, a VR based protocol could improve anxiety outcomes in PD.Clinical implications: VR in PD provides control of a patient's field of view, which can be exploited to induce specific responses, provide visual feedback, analysis of patient actions, and introduce safe challenges in the context of training. VR assisted Cognitive Behavioral Therapy (CBT) tailored to suit subtypes of anxiety disorders in PD have the potential to improve the efficacy and effectiveness of psychotherapy in PD.

Slow Breathing Exercise with Multimodal Virtual Reality: A Feasibility Study

Many studies have shown that slow breathing training is beneficial for human health. However, several factors might discourage beginners from continuing their training. For example, a long training period is generally required for benefit realization, and there is no real-time feedback to trainees to adjust their breathing control strategy. To raise the user’s interest in breathing exercise training, a virtual reality system with multimodal biofeedback is proposed in this work. In our system, a realistic human model of the trainee is provided in virtual reality (VR). At the same time, abdominal movements are sensed, and the breathing rate can be visualized. Being aware of the breathing rate, the trainee can regulate his or her breathing to achieve a slower breathing rate. An additional source of tactile feedback is combined with visual feedback to provide a more immersive experience for the trainees. Finally, the user’s satisfaction with the proposed system is reported through questionnaires. Most of the users find it enjoyable to use such a system for mediation training.

Cueing Paradigms to Improve Gait and Posture in Parkinson's Disease: A Narrative Review

Progressive gait dysfunction is one of the primary motor symptoms in people with Parkinson’s disease (PD). It is generally expressed as reduced step length and gait speed and as increased variability in step time and step length. People with PD also exhibit stooped posture which disrupts gait and impedes social interaction. The gait and posture impairments are usually resistant to the pharmacological treatment, worsen as the disease progresses, increase the likelihood of falls, and result in higher rates of hospitalization and mortality. These impairments may be caused by perceptual deficiencies (poor spatial awareness and loss of temporal rhythmicity) due to the disruptions in processing intrinsic information related to movement initiation and execution which can result in misperceptions of the actual effort required to perform a desired movement and maintain a stable posture. Consequently, people with PD often depend on external cues during execution of motor tasks. Numerous studies involving open-loop cues have shown improvements in gait and freezing of gait (FoG) in people with PD. However, the benefits of cueing may be limited, since cues are provided in a consistent/rhythmic manner irrespective of how well a person follows them. This limitation can be addressed by providing feedback in real-time to the user about performance (closed-loop cueing) which may help to improve movement patterns. Some studies that used closed-loop cueing observed improvements in gait and posture in PD, but the treadmill-based setup in a laboratory would not be accessible outside of a research setting, and the skills learned may not readily and completely transfer to overground locomotion in the community. Technologies suitable for cueing outside of laboratory environments could facilitate movement practice during daily activities at home or in the community and could strongly reinforce movement patterns and improve clinical outcomes. This narrative review presents an overview of cueing paradigms that have been utilized to improve gait and posture in people with PD and recommends development of closed-loop wearable systems that can be used at home or in the community to improve gait and posture in PD.

The role of virtual reality on outcomes in rehabilitation of Parkinson's disease: meta-analysis and systematic review in 1031 participants

Introduction

Parkinson’s disease (PD) is managed primarily by dopamine agonists and physiotherapy while virtual reality (VR) has emerged recently as a complementary method. The present study reviewed the effectiveness of VR in rehabilitation of patients with PD.

Methods

Literature search up to June 2019 identified ten studies (n = 343 participants) suitable for meta-analysis and 27 studies (n = 688 participants) for systematic review. Standard mean difference (SMD) and 95% confidence intervals (CI) were calculated using a random effects model.

Results

In meta-analysis, compared with active rehabilitation intervention, VR training led to greater improvement of stride length, SMD = 0.70 (95%CI = 0.32–1.08, p = 0.0003), and was as effective for gait speed, balance and co-ordination, cognitive function and mental health, quality of life and activities of daily living. Compared with passive rehabilitation intervention, VR had greater effects on balance: SMD = 1.02 (95%CI = 0.38–1.65, p = 0.002). Results from single randomised controlled trials showed that VR training was better than passive rehabilitation intervention for improving gait speed SMD = 1.43 (95%CI = 0.51–2.34, p = 0.002), stride length SMD = 1.27 (95%CI = 0.38–2.16, p = 0.005) and activities of daily living SMD = 0.96 (95%CI = 0.02–1.89). Systematic review showed that VR training significantly (p < 0.05) improved motor function, balance and co-ordination, cognitive function and mental health, and quality of life and activities of daily living.

Conclusion

VR used in rehabilitation for patients with PD improves a number of outcomes and may be considered for routine use in rehabilitation.

Electronic supplementary material

The online version of this article (10.1007/s10072-019-04144-3) contains supplementary material, which is available to authorized users.

Virtual Reality Rehabilitation Versus Conventional Physical Therapy for Improving Balance and Gait in Parkinson's Disease Patients: A Randomized Controlled Trial

BACKGROUND The aim of this study was to investigate the effect of virtual reality (VR) technology on balance and gait in patients with Parkinson's disease (PD). MATERIAL AND METHODS The study design was a single-blinded, randomized, controlled study. Twenty-eight patients with PD were randomly divided into the experimental group (n=14) and the control group (n=14). The experimental group received VR training, and the control group received conventional physical therapy. Patients performed 45 minutes per session, 5 days a week, for 12 weeks. Individuals were assessed pre- and post-rehabilitation with the Berg Balance Scale (BBS), Timed Up and Go Test (TUGT), Third Part of Unified Parkinson's Disease Rating Scale (UPDRS3), and Functional Gait Assessment (FGA). RESULTS After treatment, BBS, TUGT, and FGA scores had improved significantly in both groups (P<0.05). However, there was no significant difference in the UPDRS3 between the pre- and post-rehabilitation data of the control group (P>0.05). VR training resulted in significantly better performance compared with the conventional physical therapy group (P<0.05). CONCLUSIONS The results of this study indicate that 12 weeks of VR rehabilitation resulted in a greater improvement in the balance and gait of individuals with PD when compared to conventional physical therapy.

Feasibility of Eye Tracking Assisted Vestibular Rehabilitation Strategy Using Immersive Virtual Reality

OBJECTIVES

Even though vestibular rehabilitation therapy (VRT) using head-mounted display (HMD) has been highlighted recently as a popular virtual reality platform, we should consider that HMD itself do not provide interactive environment for VRT. This study aimed to test the feasibility of interactive components using eye tracking assisted strategy through neurophysiologic evidence.

METHODS

HMD implemented with an infrared-based eye tracker was used to generate a virtual environment for VRT. Eighteen healthy subjects participated in our experiment, wherein they performed a saccadic eye exercise (SEE) under two conditions of feedback-on (F-on, visualization of eye position) and feedback-off (F-off, non-visualization of eye position). Eye position was continuously monitored in real time on those two conditions, but this information was not provided to the participants. Electroencephalogram recordings were used to estimate neural dynamics and attention during SEE, in which only valid trials (correct responses) were included in electroencephalogram analysis.

RESULTS

SEE accuracy was higher in the F-on than F-off condition (P=0.039). The power spectral density of beta band was higher in the F-on condition on the frontal (P=0.047), central (P=0.042), and occipital areas (P=0.045). Beta-event-related desynchronization was significantly more pronounced in the F-on (-0.19 on frontal and -0.22 on central clusters) than in the F-off condition (0.23 on frontal and 0.05 on central) on preparatory phase (P=0.005 for frontal and P=0.024 for central). In addition, more abundant functional connectivity was revealed under the F-on condition.

CONCLUSION

Considering substantial gain may come from goal directed attention and activation of brain-network while performing VRT, our preclinical study from SEE suggests that eye tracking algorithms may work efficiently in vestibular rehabilitation using HMD.

Using an interactive virtual environment to integrate a digital Action Research Arm Test, motor imagery and action observation to assess and improve upper limb motor function in patients with neuromuscular impairments: a usability and feasibility study protocol

INTRODUCTION

In the recent past, training systems using an interactive virtual environment have been introduced to neurorehabilitation. Such systems can be applied to encourage purposeful limb movements and will increasingly be used at home by the individual patient. Therefore, an integrated valid and reliable assessment tool on the basis of such a system to monitor the recovery process would be an essential asset.

OBJECTIVES

The aim of the study is to evaluate usability, feasibility and validity of the digital version of the Action Research Arm Test using the Bi-Manu-Trainer system as a platform. Additionally, the feasibility and usability of the implementation of action observation and motor imagery tasks into the Bi-Manu-Trainer software will be evaluated.

PATIENTS AND METHODS

This observational study is planned as a single-arm trial for testing the new assessment and the action observation and motor imagery training module. Therefore, 75 patients with Parkinson's disease, multiple sclerosis, stroke, traumatic brain injury or Guillain-Barré syndrome will be included. 30 out of the 75 patients will additionally take part in a 4-week training on the enhanced Bi-Manu-Trainer system. Primary outcomes will be the score on the System Usability Scale and the correlation between the conventional and digital Action Research Arm Test scores. Secondary outcomes will be hand dexterity, upper limb activities of daily living and quality of life.

HYPOTHESIS

We hypothesise that the digital Action Research Arm Test assessment is a valid and essential tool and that it is feasible to incorporate action observation and motor imagery into Bi-Manu-Trainer practice. The results are expected to give recommendations for necessary modifications and might also contribute knowledge concerning the application of action observation and motor imagery tasks using a training system such as the Bi-Manu-Trainer.

TRIAL REGISTRATION NUMBER

NCT03268304; Pre-results.

[Paradoxical kinesia in Parkinson's disease: theories and practical application]

This literature review addresses the phenomenon of paradoxical kinesia (PK) in patients with Parkinson's disease (PD). PK is the sudden ability of the patient wit hPD to perform movements that were previously disturbed. This ability can be caused by different internal or environmental stressors. Different theories explaining the mechanism of paradoxical kinesia were proposed. In recent years, in the context of a search for new effective methods of treatment of akinesia I PD, methods of correction of motor impairment based on the phenomenon of PK are being developed.

Effects of Auditory Rhythm and Music on Gait Disturbances in Parkinson's Disease

Gait abnormalities, such as shuffling steps, start hesitation, and freezing, are common and often incapacitating symptoms of Parkinson’s disease (PD) and other parkinsonian disorders. Pharmacological and surgical approaches have only limited efficacy in treating these gait disorders. Rhythmic auditory stimulation (RAS), such as playing marching music and dance therapy, has been shown to be a safe, inexpensive, and an effective method in improving gait in PD patients. However, RAS that adapts to patients’ movements may be more effective than rigid, fixed-tempo RAS used in most studies. In addition to auditory cueing, immersive virtual reality technologies that utilize interactive computer-generated systems through wearable devices are increasingly used for improving brain–body interaction and sensory–motor integration. Using multisensory cues, these therapies may be particularly suitable for the treatment of parkinsonian freezing and other gait disorders. In this review, we examine the affected neurological circuits underlying gait and temporal processing in PD patients and summarize the current studies demonstrating the effects of RAS on improving these gait deficits.

Visual Hallucinations as Incidental Negative Effects of Virtual Reality on Parkinson's Disease Patients: A Link with Neurodegeneration?

We followed up a series of 23 Parkinson's disease (PD) patients who had performed an immersive virtual reality (VR) protocol eight years before. On that occasion, six patients incidentally described visual hallucinations (VH) with occurrences of images not included in the virtual environment. Curiously, in the following years, only these patients reported the appearance of VH later in their clinical history, while the rest of the group did not. Even considering the limited sample size, we may argue that VR immersive systems can induce unpleasant effects in PD patients who are predisposed to a cognitive impairment.