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

Metaverse for Exercise Rehabilitation: Possibilities and Limitations

OBJECTIVES

This study aimed to obtain a consensus agreement from an expert panel on the metaverse for exercise rehabilitation in stroke patients using the Delphi technique.

METHODS

This study recruited twenty-two experts and conducted three rounds of online surveys between January and February 2023. The Delphi consensus technique was performed online to review and evaluate the framework module. A panel of experts, including scholars, physicians, physical therapists, and physical education specialists in the Republic of Korea, was invited to participate in this study. For each round, the expert consensus was defined as more than 90% of the expert panel agreeing or strongly agreeing with the proposed items.

RESULTS

A total of twenty experts completed the three Delphi rounds. First, virtual reality-assisted (VR) treadmill walking could improve cognitive function, concentration, muscular endurance, stroke prevention, proper weight maintenance, and cardiorespiratory function. Second, related technology, safety, price, place, and securing experts would be obstacles or challenges in VR-assisted treadmill walking for stroke patients. Third, the role of exercise instructors in exercise planning, performance, and assessment for VR-assisted treadmill walking is equally important, and reeducation for them is required. Fourth, VR-assisted treadmill walking for stroke patients requires an exercise intensity of at least five times a week, about one hour each time.

CONCLUSIONS

This study showed that the metaverse for exercise rehabilitation for stroke patients could be successfully developed and would be feasible to be implemented in the future. However, it would have limitations in terms of technology, safety, price, place, and expert factors to be overcome in the future.

Transcranial direct current stimulation combined with bodyweight support-tai chi footwork for motor function of stroke survivors: a study protocol of randomised controlled trial

INTRODUCTION

Our previous studies have proposed the bodyweight support-t'ai chi (BWS-TC) footwork training for stroke survivors with severe motor dysfunction and fear of falling, and have proven its positive effects for motor function. Transcranial direct current stimulation (tDCS) provides a non-invasive and safe way to modulate neuronal activity and provoke neuroplastic changes and to improve the motor function of stroke survivors. However, it is unclear whether the integration of BWS-TC and tDCS has synergistic effects on improving motor function of the stroke survivors.

METHODS AND ANALYSIS

This study will be an assessor-blinded randomised controlled trial involving 12-week intervention and 6-month follow-up. One hundred and thirty-five individuals with stroke will be randomly divided in a ratio of 1:1:1 into three groups. Control group A, control group B and intervention group C will receive tDCS and conventional rehabilitation programmes (CRPs), BWS-TC and CRP, tDCS-BWS-TC and CRP for 12 weeks, respectively. The primary outcome measures will include the efficacy (Fugl-Meyer Assessment), acceptability and safety of these interventions. The secondary outcome measures will include balance ability (ie, limits of stability and modified clinical test of sensory integration), walking function, brain structure and function, risk of falling, Barthel Index and 36-Item Short Form Survey. All outcomes will be assessed at baseline, 6 and 12 weeks during intervention, and 1, 3 and 6 months during the follow-up period. Two-way analysis of variance with repeated measures will be applied to examine the main effects of the group and the time factor and group-time interaction effects for all outcome measures.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the ethics committee of the Shanghai Seventh People's Hospital (2021-7th-HIRB-017). The results of the study will be published in a peer-reviewed journal and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2200059329.

Balance Rehabilitation through Robot-Assisted Gait Training in Post-Stroke Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Balance impairment is a common disability in post-stroke survivors, leading to reduced mobility and increased fall risk. Robotic gait training (RAGT) is largely used, along with traditional training. There is, however, no strong evidence about RAGT superiority, especially on balance. This study aims to determine RAGT efficacy on balance of post-stroke survivors.

METHODS

PubMed, Cochrane Library, and PeDRO databases were investigated. Randomized clinical trials evaluating RAGT efficacy on post-stroke survivor balance with Berg Balance Scale (BBS) or Timed Up and Go test (TUG) were searched. Meta-regression analyses were performed, considering weekly sessions, single-session duration, and robotic device used.

RESULTS

A total of 18 trials have been included. BBS pre-post treatment mean difference is higher in RAGT-treated patients, with a pMD of 2.17 (95% CI 0.79; 3.55). TUG pre-post mean difference is in favor of RAGT, but not statistically, with a pMD of -0.62 (95%CI - 3.66; 2.43). Meta-regression analyses showed no relevant association, except for TUG and treatment duration (β = -1.019, 95% CI - 1.827; -0.210, p-value = 0.0135).

CONCLUSIONS

RAGT efficacy is equal to traditional therapy, while the combination of the two seems to lead to better outcomes than each individually performed. Robot-assisted balance training should be the focus of experimentation in the following years, given the great results in the first available trials. Given the massive heterogeneity of included patients, trials with more strict inclusion criteria (especially time from stroke) must be performed to finally define if and when RAGT is superior to traditional therapy.

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.

Aphasia improvement without logotherapy during motor neurorehabilitation of post-stroke hemiparesis using virtual reality or modified constraint-induced movement therapy: A retrospective cohort

BACKGROUND

Some research suggests that post-stroke aphasia can recover "on its own", however, there is evidence of a common neural substrate for motor and language systems. We hypothesize, that motor neurorehabilitation of hemiparesis could be related to simultaneous improvement in aphasia.

OBJECTIVE

To measure changes in post-stroke aphasia and its relation with hemiparesis treated with different therapies.

METHODS

Database information (n = 32) on post-stroke hemiparesis (Fugl-Meyer Scale evaluated) managed with virtual reality (VR) versus modified constraint-induced movement therapy (mCIMT) or regular therapy (rPT/OT) was analyzed. None received logotherapy (LT) by appointment at four months.

INCLUSION CRITERIA

< 3 months after the stroke, aphasia severe (Boston Aphasia Intensity Scale), and all three evaluations.

RESULTS

Twenty-one patient records met inclusion criteria (71,4% women and mean age 66,67±3,13 years) who received VR, mCIMT, or rPT/OT (n = 6, 8, and 7, respectively). There was continuous intra-groups improvement in aphasia (p < 0.05), but inter-groups the greater aphasia recovery (p = 0.05) and hemiparesis (p = 0.02) were in VR, with a high correlation in evolution between them (r = 0.73; p = 0.047).

CONCLUSION

High clinical correlation between aphasia, without LT, and hemiparesis evolution during motor neurorehabilitation would support common neural connections stimulation. We will conduct a clinical trial, with a larger sample size to contrast our hypothesis.

A meta-analysis of studies of the effects of case management intervention for stroke survivors across three countries

PURPOSE

A stroke survivor who is discharged to home care faces many challenges during the transition from the hospital to home, including managing their care at home and engaging in rehabilitation and recovery. Case management was developed to ease the transition from hospital to home and help people with stroke cope with their care management challenges. However, the effects of case management intervention remain inconclusive. Case management was designed to direct care and may represent a novel method for reducing the burden of care. This study was designed to evaluate the effects of case management interventions on mental health outcomes, activities of daily living capacity, physical function, and social function among stroke survivors.

DESIGN

Systematic review and meta-analysis.

METHODS

This study included studies examining the impacts of case management interventions for stroke survivors that were published in English and identified by searching eight databases, from database inception to February 20, 2022. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were used to pool effect sizes using a random-effects model (in Stata 16.0). The revised Cochrane risk-of-bias tool for randomized trials (RoB-2) was used to assess the methodological quality of each study.

FINDINGS

The inclusion criteria were satisfied by eight studies (including a total of 1119 stroke survivors). Case management had positive effects on mental health (SMD: 0.26; 95% CI: 0.07 to 0.45, p = 0.001) and activities of daily living (SMD: 0.68; 95% CI: 00.37 to 0.99, p < 0.001). However, no significant effects were observed for either physical function or social function.

CONCLUSION

Case management appears to enhance the mental health and activities of daily living among stroke survivors.

CLINICAL RELEVANCE

Case management interventions hold promise as efficient, cost-effective, and accessible strategies to positively influence care for stroke survivors. This intervention strategy could be applied to the hospital-to-home transition to guide care among this population.

Systematic review on post-stroke computerized cognitive training: Unveiling the impact of confounding factors

Background

Stroke is a highly incapacitating disease that can lead to disabilities due to cognitive impairment, physical, emotional, and social sequelae, and a decrease in the quality of life of those affected. Moreover, it has been suggested that cognitive reserve (patients' higher levels of education or having a skilled occupation), for instance, can promote faster cognitive recovery after a stroke. For this reason, this review aims to identify the cognitive, functional, and behavioral effects of computerized rehabilitation in patients aged 50 years or older who had a stroke, considering cognitive reserve proxies.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-PRISMA, and performed the search for peer-reviewed randomized controlled trials without a date restriction on CINAHL, LILACS, PubMed, Scopus, and Web of Science databases were chosen.

Results

We screened 780 papers and found 19 intervention studies, but only 4 met the inclusion criteria and shared data. These studies included computerized tools for motor and cognitive rehabilitation in the experimental groups. In all studies, computerized training was combined with other interventions, such as standard therapy, occupational therapy, and aerobic exercises. There were 104 participants affected by ischemic or hemorrhagic stroke, predominantly male (57.69%), and all with cognitive impairment.

Conclusion

Despite a limited number of studies, varied methods and insufficient information available, schooling as a CR proxy combined with high-intensity computerized cognitive training was key to mediating cognitive improvement. The systematic review also identified that the associated ischemic stroke and shorter time of onset for rehabilitation contribute to the cognitive evolution of patients. Findings do not support a greater benefit of computerized cognitive training compared to conventional cognitive therapies.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=296193], identifier [CRD42022296193].

A protocol to analyze the global literature on the clinical benefit of interlimb-coordinated intervention in gait recovery and the associated neurophysiological changes in patients with stroke

Background

Stroke is among the leading causes of disability of worldwide. Gait dysfunction is common in stroke survivors, and substantial advance is yet to be made in stroke rehabilitation practice to improve the clinical outcome of gait recovery. The role of the upper limb in gait recovery has been emphasized in the literature. Recent studies proposed that four limbs coordinated interventions, coined the term "interlimb-coordinated interventions," could promote gait function by increasing the neural coupling between the arms and legs. A high-quality review is essential to examine the clinical improvement and neurophysiological changes following interlimb-coordinated interventions in patients with stroke.

Methods

Systematic review and meta-analysis will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The literature will be retrieved from the databases of OVID, MEDLINE, PubMed, Web of Science, EMBASE, and PsycINFO. Studies published in English over the past 15 years will be included. All of the clinical studies (e.g., randomized, pseudorandomized and non-randomized controlled trials, uncontrolled trials, and case series) that employed interlimb intervention and assessed gait function of patients with stroke will be included. Clinical functions of gait, balance, lower limb functions, and neurophysiologic changes are the outcome measures of interest. Statistical analyses will be performed using the Comprehensive Meta-Analysis version 3.

Discussion

The findings of this study will provide insight into the clinical benefits and the neurophysiological adaptations of the nervous system induced by interlimb-coordinated intervention in patients with stroke. This would guide clinical decision-making and the future development of targeted neurorehabilitation protocol in stroke rehabilitation to improve gait and motor function in patients with stroke. Increasing neuroplasticity through four-limb intervention might complement therapeutic rehabilitation strategies in this patient group. The findings could also be insightful for other cerebral diseases.

Psychometric Properties of the Action Research Arm Test (ARAT) Scale in Post-Stroke Patients-Spanish Population

The validation of measuring instruments in the field of health is a requirement before they can be used safely and reliably. The action research arm test (ARAT) tool is an instrument validated in numerous countries and languages and for different populations, and its use is widespread. The objective of this research was to determine the psychometric properties of ARAT for a sample composed of post-stroke patients. To achieve this, a psychometric analysis was performed, where internal consistency tests were carried out using Cronbach's alpha, correlations between items and item-total and half-level tests to verify their reliability. Regarding validity, criteria validity tests were performed, taking the motor function dimension of the Fugl-Meyer scale as gold standard, and convergent validity tests were performed by correlation with the FIM-FAM, ECVI-38 and Lawton and Brody scales. The results showed very good internal consistency as well as good criterion and convergent validity. In conclusion, the ARAT can be considered a valid and reliable instrument for the evaluation of upper limb function in post-stroke patients.

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

Introduction

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

Materials and methods

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

Results

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

Conclusion

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

Clinical trial registration

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

Rehabilitation efficacy comparison of virtual reality technology and computer-assisted cognitive rehabilitation in patients with post-stroke cognitive impairment: A network meta-analysis

OBJECTIVE

Virtual reality (VR) and computer-assisted cognitive rehabilitation (CACR) are two emerging rehabilitation therapies for stroke patients. The aim of this study was to compare the rehabilitation efficacy of these two treatments for patients with post-stroke cognitive impairment (PSCI).

METHODS

A network search of Embase, Web of Science, PubMed, Cochrane Library, VIP, WanFang Data, and CNKI databases was performed from their inception to February 2022 for screening randomized controlled trials related to VR and CACR in the treatment of PSCI. The quality of the included studies was assessed using the Cochrane risk bias assessment tool. The primary outcomes of the included studies contained at least one of the following clinical outcome measures: Mini-mental state examination (MMSE) or Montreal Cognitive Assessment (MoCA). After screening the literature, assessing the quality and extracting the data, a network meta-analysis was performed with STATA software.

RESULTS

A total of 21 randomized controlled trials were included, including 1,047 patients. The results of network meta-analysis showed that under MMSE index, VR group (p = 0.067) and CACR group (p = 0.054) tended to be superior to CT group, but it was not significant. Both the VR (p = 0.024) and CACR (p < 0.001) groups had significantly better outcomes compared to the conventional therapy group in terms of MoCA. The ranking results under both indicators showed that CACR had the best treatment effect, followed by VR.

CONCLUSION

In general, VR and CACR have superior efficacy compared with conventional therapy, in which CACR may be the best treatment option.

[Expectations of generation Y for digital health innovations]

BACKGROUND AND AIM

"Generation Y" is the term used to describe younger adults born between approximately 1980 and 2000. The generation is attributed with being digitally savvy and technically adept. It can thus be assumed that there is an increased desire among these people to use digital healthcare innovations when needed. However, the exact expectations in this regard are largely unknown. The aim of this study is to examine the expectations and needs of Generation Y in more detail.

MATERIALS AND METHODS

For data collection, five focus group interviews were conducted in April 2021, each with six people between 23 and 36 years of age, with three people per group working in the health sector. The interview material was analyzed using content analysis according to Mayring.

RESULTS

One of the expectations among respondents was to use low-threshold digital healthcare innovations. There was also a great demand for health information. The focus was on increasing efficiency in everyday life, in particular a reduction in the amount of time required. Influences of the corona pandemic on expectations were observed.

DISCUSSION

Three functions of digital applications emerge as particularly relevant: "administration," "tracking," and "information." For these, preference profiles of Generation Y were created. Customized solutions offered by digital innovations could help to implement target-group-specific health promotion and prevention more concretely and generate added value for Generation Y. Since the everyday life of the target group is already characterized by digitization and digital innovations, there is great potential here.

Affective States and Virtual Reality to Improve Gait Rehabilitation: A Preliminary Study

Over seven million people suffer from an impairment in Mexico; 64.1% are gait-related, and 36.2% are children aged 0 to 14 years. Furthermore, many suffer from neurological disorders, which limits their verbal skills to provide accurate feedback. Robot-assisted gait therapy has shown significant benefits, but the users must make an active effort to accomplish muscular memory, which usually is only around 30% of the time. Moreover, during therapy, the patients' affective state is mostly unsatisfied, wide-awake, and powerless. This paper proposes a method for increasing the efficiency by combining affective data from an Emotiv Insight, an Oculus Go headset displaying an immersive interaction, and a feedback system. Our preliminary study had eight patients during therapy and eight students analyzing the footage using the self-assessment Manikin. It showed that it is possible to use an EEG headset and identify the affective state with a weighted average precision of 97.5%, recall of 87.9%, and F1-score of 92.3% in general. Furthermore, using a VR device could boost efficiency by 16% more. In conclusion, this method allows providing feedback to the therapist in real-time even if the patient is non-verbal and has a limited amount of facial and body expressions.

Altered effective connectivity in the emotional network induced by immersive virtual reality rehabilitation for post-stroke depression

Post-stroke depression (PSD) is a serious complication of stroke that significantly restricts rehabilitation. The use of immersive virtual reality for stroke survivors is promising. Herein, we investigated the effects of a novel immersive virtual reality training system on PSD and explored induced effective connectivity alterations in emotional networks using multivariate Granger causality analysis (GCA). Forty-four patients with PSD were equally allocated into an immersive-virtual reality group and a control group. In addition to their usual rehabilitation treatments, the participants in the immersive-virtual reality group participated in an immersive-virtual reality rehabilitation program, while the patients in the control group received 2D virtual reality rehabilitation training. The Hamilton Depression Rating Scale, modified Barthel Index (MBI), and resting-state functional magnetic resonance imaging (rsfMRI) data were collected before and after a 4-week intervention. rsfMRI data were analyzed using multivariate GCA. We found that the immersive virtual reality training was more effective in improving depression in patients with PSD but had no statistically significant improvement in MBI scores compared to the control group. The GCA showed that the following causal connectivities were strengthened after immersive virtual reality training: from the amygdala, insula, middle temporal gyrus, and caudate nucleus to the dorsolateral prefrontal cortex; from the insula to the medial prefrontal cortex; and from the thalamus to the posterior superior temporal sulcus. These causal connectivities were weakened after treatment in the control group. Our results indicated the neurotherapeutic use of immersive virtual reality rehabilitation as an effective non-pharmacological intervention for PSD; the alteration of causal connectivity in emotional networks might constitute the neural mechanisms underlying immersive-virtual reality rehabilitation in PSD.

Update on Stroke Rehabilitation for Non-Motor Impairment

Various interventions exist to treat non-motor impairments caused by stroke. Adjuvant treatments such as non-invasive brain stimulation, virtual reality, computer-assisted training, neurostimulation, and biofeedback are being investigated and applied in the areas of cognitive dysfunction, language problems, visual disorders, dysphagia, mood disorders, and post-stroke pain. Most of these treatments have shown efficacy and symptom improvement, but further investigation is required to fully clarify their effects.

Brazilian practice guidelines for stroke rehabilitation: Part II

The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

Update on Stroke Rehabilitation in Motor Impairment

Motor impairment due to stroke limits patients' mobility, activities of daily living, and negatively affects their return to the workplace. It also reduces patients' quality of life and increases the socioeconomic burden of stroke. Therefore, optimizing the recovery of motor impairment after stroke is a very important goal for both individuals and society as a whole. The emergence and improvement of various technologies in the Fourth Industrial Revolution have exerted a major influence on the development of new rehabilitation methods and efficiency enhancements for existing methods. This review categorizes rehabilitation methods that promote the recovery of motor function into upper limb function and lower limb function and summarizes recent advances in stroke rehabilitation. Although debate continues regarding the effects of some rehabilitation therapies, it is hoped that the evidence will be improved through ongoing research so that clinicians can treat patients with a higher level of evidence.

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.

Efficacy of Virtual Reality-Based Rehabilitation Interventions to Improve Balance Function in Patients with Cerebral Palsy: A Systematic Review and Meta-analysis of RCTs

Context: Cerebral palsy (CP) results from damage to the central nervous system, leading to disturbances of motor and sensory functions, especially the balance. Virtual reality exercise intervention (VRI) is a promising technique to improve motor function in children with CP by engaging such individuals in real-like world events through simulations. This review study examines the effects of VRI on static and functional balances and summarizes the effective protocols of virtual reality-based rehabilitation interventions for the CP patients. Methods: A comprehensive search was performed using the following databases: Medline/PubMed, Scopus, Cochrane Library, PEDro, EBSCOhost, and the Online Library of the University of London. The PEDro scale was used to assess the methodological quality. The data extracted from the reviewed studies were coded according to Cooper and Hedges’ guidelines considering the following criteria: (I) Patients' characteristics, (II) intervention protocols, (III) outcomes, and (IV) results. To this end, twelve RCTs with 248 patients aged 4 - 20 years old were analyzed and assessed as "fair" to "good" methodological quality according to Pedro’s scale (4 to 8). VRI alone or in combination with a standard physiotherapy program or with other tools such as tDCS was applied. Results: Twelve RCTs met the inclusion criteria. The meta-analysis showed the good effect of VRI on the static and functional balances of patients with CP (Cohen’s d = 0.66). The funnel plot revealed no significant asymmetry or heterogeneity among the studies (P = 0.271, I2 = 19.71%), reflecting the absence of publication biases. Conclusions: This review reports four major perspectives of the VRI applications: (1) VRI settings, (2) selection of exercises, (3) outcome measures, and (4) long-term effects. Moreover, this review summarizes the specific effects of VRI on balance improvement in patients with CP from different perspectives. However, considering the limited number of well-conducted RCTs in this field, a large homogeneous samples size is still needed for future RCTs.

Effects of Robot-Assisted Gait Training with Body Weight Support on Gait and Balance in Stroke Patients

This study investigated the effects of robot-assisted gait training with body weight support on gait and balance in stroke patients. The study participants comprised 24 patients diagnosed with stroke. Patients were randomly assigned to four groups of six: robot A, B, C, and non-robot. The body weight support (BWS) for the harness of the robot was set to 30% of the patient’s body weight in robot group A, 50% in robot group B, and 70% in robot group C. All experimental groups received robot-assisted gait training and general physical therapy. The non-robot group underwent gait training using a p-bar, a treadmill, and general physical therapy. The intervention was performed for 30 min a day, five times a week, for 6 weeks. All participants received the intervention after the pre-test. A post-test was performed after all of the interventions were completed. Gait was measured using a 10 m Walking test (10MWT) and the timed up and go (TUG) test. Balance was assessed using the Berg Balance Scale (BBS). Robot groups A, B, and C showed significantly better 10MWT results than did the non-robot group (p < 0.5). TUG was significantly shorter in robot groups A, B, and C than in the non-robot group (p < 0.5). The BBS scores for robot group A improved significantly more than did those for robot groups B and C and the non-robot group (p < 0.5), indicating that robot-assisted gait training with body weight support effectively improved the gait of stroke patients.

Exergaming for Physical Therapy in Patients with Down Syndrome: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials

The aim of this systematic review and meta-analysis of randomized-controlled trials was to analyze the effectiveness of exergaming on motor outcomes compared with control in patients with Down syndrome. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was performed up to July 2021 in the following scientific databases: PubMed, CENTRAL, CINAHL, Medline, Scopus, Web of Science, BioMed Central, and Physiotherapy Evidence Database (PEDro). The study eligibility criteria were previously established according to the PICOS model. The PEDro scale was used to assess the methodological quality of the studies, and the Cochrane Collaboration's tool was used to assess the risk of bias. A meta-analysis using standardized mean difference (SMD) and confidence interval (95% CI) was performed using the Review Manager 5.4 software. Eight articles were included in the systematic review and meta-analysis. Statistical analysis showed favorable results for exergaming on balance (SMD = 2.72; 95% CI = 1.68-3.76), functional mobility (SMD = 4.14; 95% CI = 3.69-4.59), and muscle strength (SMD = 6.40; 95% CI = 2.68-10.11). No conclusive results were found on aerobic endurance. In conclusion, the results show the potential benefits of exergaming to recover motor outcomes in patients with Down syndrome, specifically, in balance, functional mobility, and muscle strength. We encourage researchers and clinicians to integrate exergaming in clinical settings since it is an inexpensive and easily accessible therapy for different populations, and it could be a useful tool within the physical therapy interventions in patients with Down syndrome. PROSPERO registration number: CRD42021238335.

Emerging Limb Rehabilitation Therapy After Post-stroke Motor Recovery

Stroke, including hemorrhagic and ischemic stroke, refers to the blood supply disorder in the local brain tissue for various reasons (aneurysm, occlusion, etc.). It leads to regional brain circulation imbalance, neurological complications, limb motor dysfunction, aphasia, and depression. As the second-leading cause of death worldwide, stroke poses a significant threat to human life characterized by high mortality, disability, and recurrence. Therefore, the clinician has to care about the symptoms of stroke patients in the acute stage and formulate an effective postoperative rehabilitation plan to facilitate the recovery in patients. We summarize a novel application and update of the rehabilitation therapy in limb motor rehabilitation of stroke patients to provide a potential future stroke rehabilitation strategy.

Effects of Exergaming in Patients with Cardiovascular Disease Compared to Conventional Cardiac Rehabilitation: A Systematic Review and Meta-Analysis

Background: Exercise-based cardiac rehabilitation (CR) programs are used for improving prognosis and quality of life in patients with cardiovascular disease (CVD). Nonetheless, adherence to these programs is low, and exercise-based CR programs based on virtual reality (i.e., exergaming) have been proposed as an alternative to conventional CR programs. However, whether exergaming programs are superior to conventional CR programs in patients with CVD is not known. Objective: This systematic review with meta-analysis was conducted to explore whether exergaming enhances exercise capacity, quality of life, mental health, motivation, and exercise adherence to a greater extent than conventional CR programs in patients with CVD. Method: Electronic searches were carried out in PubMed, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases up to June 2021. Meta-analyses were performed using robust variance estimation with small-sample corrections. The effect sizes were calculated as the mean differences (MD) or standardized mean differences (SMD) as appropriate. The SMD magnitude was classified as trivial (<0.20), small (0.20−0.49), medium (0.50−0.79), or large (≥0.80). Heterogeneity was interpreted based on the I2 statistics as low (25%), moderate (50%), or high (75%). Results: Pooled analyses showed no differences between exergaming and conventional CR programs for enhancing exercise capacity (i.e., distance covered in the six-minute walk test) (MD+ = 14.07 m (95% confidence interval (CI) −38.18 to 66.32 m); p = 0.426) and mental health (SMD+ = 0.17 (95% CI −0.36 to 0.70); p = 0.358). The results showed a small, statistically nonsignificant improvement in quality of life in favor of exergaming (SMD+ = 0.22 (95% CI = −0.37 to 0.81); p = 0.294). Moderate heterogeneity was found for exercise capacity (I2 = 53.7%), while no heterogeneity was found for quality of life (I2 = 3.3%) and mental health (I2 = 0.0%). Conclusions: Exergaming seems not to be superior to conventional CR programs for improving exercise capacity, quality of life, or mental health in patients with CVD.

Effects of Balance Training Using a Virtual Reality Program in Hemiplegic Patients

Therapeutic goals for hemiplegic patients with neurological impairments are mainly focused on improving their independent lives. Based on the previously reported effectiveness of Wii Fit balance training, this study investigated the most influential outcomes after long-term intensive training (including balance and functional factors) on quality of life in hemiplegic patients. The intervention group (n = 21) received Nintendo Wii Fit balance training under supervision, and control group (n = 20) received conventional balance training by an occupational therapist. Two groups were matched based on age and onset duration. Both groups received a total of 15 treatments for 30 min per session, twice a week for 8 weeks. There were significant improvements not only in balance confidence and activities of daily living, but also in body composition, such as fat proportion and metabolic rate, in the intervention group compared to the control group (p < 0.05). In particular, balance confidence significantly affected EuroQoL Visual Analogue Scale according to stepwise multiple regression analyses in this study. These results demonstrated that Wii Fit balance training using virtual reality improved the quality of life of hemiplegic patients while overcoming the asymmetrical weight distribution of the affected side via the self-modulating biofeedback exercises.

How Many Hours of Device Wear Time Are Required to Accurately Measure Physical Activity Post Stroke?

Background. Inadequate physical activity participation is a risk factor for secondary stroke. Before implementing appropriate management strategies, we need to accurately measure the physical activity of stroke survivors. We aimed to determine the duration of physical activity monitoring post-stroke that constitutes a valid day. Methods. We sampled stroke survivors’ physical activity for one week following discharge from inpatient rehabilitation using the Sensewear Armband (Bodymedia, Pittsburgh, PA, USA). To determine the impact of total daily wear time on activity estimate (sedentary, light, and moderate to vigorous physical activity) accuracy, we performed simulations, removing one, two, three, or four hours from a 14-h reference day, and analysed them with linear mixed models. Results. Sixty-nine participants (46 male, 65 ± 15 years) with 271 days of physical activity data were included. All physical activity variables were significantly underestimated for all data sets (10, 11, 12, or 13 h) compared to the 14-h reference data set. The number of days classified as not meeting physical activity recommendations increased as daily monitoring duration decreased: 13% misclassification with 10-h compared to 14-h dataset (p = 0.011). Conclusions. The accuracy of physical activity estimates increases with longer daily monitoring periods following stroke, and researchers should aim to monitor post-stroke physical activity for 14 daytime hours.

[Mobilization of Intensive Care Unit Patients: How Can the ICU Rooms and Modern Medical Equipment Help?]

Intensive Care Unit patients frequently develop physical impairments, mainly weakness, during their ICU stay. Early mobilization is a central therapeutic element in patients on an intensive care unit to prevent and treat these physical sequelae to conserve independence. Different barriers such as lacking patient motivation, insufficient staffing and fear of dislocating vascular access or the airway led to insufficient implementation of current guideline recommendation. Integration of modern medical equipment as well as the adequate ICU room concepts is a promising option to overcome those barriers.Allowing for sufficient free floor area when planning an ICU - maybe through the integration of mobile elements - is likely to ease early mobilization and should be thoroughly considered when building or remodeling an ICU. Furthermore, wireless monitoring has been deemed necessary and could potentially decrease the fear regarding dislocation due to less cable or lines that need to be managed during mobilization.Virtual reality is a rapidly evolving field and while in ICU patients it could so far only show to reduce stress level it has been shown to improve rehabilitation in stroke patients. It is imaginable that its integration in mobilization on the ICU will boost patients' motivation. Trials are still outstanding.Robotics integrated in the ICU bed or in form of exoskeletons are currently being piloted in critically ill patients with many expected benefits due to the ability to support patients tailored to their individual needs, reduce staff requirements as the robotics will cover support function and improved duration and intensity of mobilization as for example the patient can be ambulated without ever leaving the bed, which also translates into potentially reduced fear regarding dislocation of the airway or vascular access.Currently, evidence on the benefits regarding the integration of ICU rooms as well as modern medical technology into the process of (early) mobilization is lacking but especially in the sector of robotics a huge potential is to be suspected.

Effects of virtual reality in improving upper extremity function after stroke: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the effect of virtual reality on arm motor impairment, activity limitation, participation restriction, and quality of life in patients with stroke. To determine potential moderators that affect the efficacy of virtual reality.

DATA SOURCES

CINAHL, Medline, PubMed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang Data from inception to October 23, 2021.

REVIEW METHODS

Randomized controlled trials that investigated the effect of virtual reality on arm recovery in adult patients with stroke compared to conventional therapy or sham control were included. Physiotherapy Evidence Database Scale was used to assess the methodological quality of each study.

RESULTS

Forty studies with 2018 participants were identified. Quality of included studies was fair to high. Virtual reality exhibited better effects on overall arm function (g = 0.28, p < 0.001), motor impairment (g = 0.36, p < 0.001) and activity limitation (daily living) (g = 0.24, p < 0.001) compared with the control group. No significant improvement was observed in participation restriction and activity limitation (specific task). The result for quality of life was described qualitatively. Subgroup analyses demonstrated that immersive virtual reality produced a greater beneficial effect (g = 0.60, p < 0.001). Patients with moderate to severe arm paresis could make more progress after training (g = 0.71, p < 0.001).

CONCLUSION

Virtual reality is recommended for improving motor impairment and activities of daily living after stroke and is favorable to patients with moderate to severe paresis. An immersive design could produce greater improvement.

Effects of Virtual Reality-Based Intervention on Cognition, Motor Function, Mood, and Activities of Daily Living in Patients With Chronic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: The efficacy of virtual reality (VR)-based intervention for improving cognition in patients with the chronic stage of stroke is controversial. The aims of this meta-analysis were to evaluate the effect of VR-based training combined with traditional rehabilitation on cognition, motor function, mood, and activities of daily living (ADL) after chronic stroke. Methods: The search was performed in the Cochrane Library (CENTRAL), EBSCO, EMBASE, Medline (OVID), Web of Science databases, PubMed, CINAHL Ovid, and Scopus from inception to May 31, 2021. All included studies were randomized controlled trials (RCTs) examining VR-based intervention combined with traditional rehabilitation for chronic stroke. The main outcomes of this study were cognition, including overall cognition (combined with all cognitive measurement results), global cognition (measured by the Montreal Cognitive Assessment, MoCA, and/or Mini-Mental State Examination, MMSE), and attention/execution. The additional outcomes were motor function, mood, and ADL. Subgroup analyses were conducted to verify the potential factors for heterogeneity. Results: Six RCTs including 209 participants were included for systematic review, and five studies of 177 participants were included in meta-analyses. Main outcome analyses showed large and significant effect size (ES) of VR-based training on overall cognition (g = 0.642; 95% CI = 0.134-1.149; and P = 0.013) and attention/execution (g = 0.695; 95% CI = 0.052-1.339; and P = 0.034). Non-significant result was found for VR-based intervention on global cognition (g = 0.553; 95% CI = -0.273-1.379; and P = 0.189). Additional outcome analyses showed no superiority of VR-based intervention over traditional rehabilitation on motor function and ADL. The ES of VR-based intervention on mood (g = 1.421; 95% CI = 0.448-2.393; and P = 0.004) was large and significant. In the subgroup analysis, large effects for higher daily intensity, higher weekly frequency, or greater dose of VR intervention were found. Conclusion: Our findings indicate that VR-based intervention combined with traditional rehabilitation showed better outcomes for overall cognition, attention/execution, and depressive mood in individuals with chronic stroke. However, VR-based training combined with traditional rehabilitation showed a non-significant effect for global cognition, motor function, and ADL in individuals with chronic stroke.

Effects of telehealth interventions on performing activities of daily living and maintaining balance in stroke survivors: A systematic review and meta-analysis of randomised controlled studies

BACKGROUND

Stroke is one of the most common causes of disability worldwide. In recent years, diverse telehealth programmes for stroke survivors have suggested that this mode of rehabilitation could improve stroke survivors' abilities to perform activities of daily living (ADLs) and maintain balance. Although increasingly utilised in clinical and community settings, the effectiveness of telehealth interventions in stroke survivors remains inconclusive. This warrants investigation so that telehealth interventions are evidence-based and are not merely modalities of convenience.

AIM

To identify the effects of telehealth interventions on the ability to perform ADLs and maintain balance in stroke survivors.

DESIGN

A systematic literature review and meta-analysis were conducted in accordance with PRISMA guidelines.

METHODS

A systematic literature search was performed using seven databases for literature dated up to April 25, 2021. The revised Cochrane risk of bias tool for randomised trials was used to assess the methodological quality of the included studies. A meta-analysis was performed using a random-effects model to calculate the pooled effects of telehealth interventions. Stata 16.0 was used for the statistical analyses.

RESULTS

A total of 14 studies with 1,367 participants were included in the analysis. Overall, telehealth interventions were effective in improving stroke survivors' abilities to carry out their ADLs (standardised mean difference: .45; 95% confidence interval: .12 to .78); however, no significant effects were found on balance.

CONCLUSION

Telehealth interventions are beneficial for improving stroke survivors' performance of their ADLs. Future telehealth intervention trials should focus on identifying essential intervention delivery components that facilitate intervention adoption by clinicians and stroke survivors and sustain the positive effects on stroke survivors' performance of their ADLs in different settings.

RELEVANCE TO CLINICAL PRACTICE

It is essential to build flexibility in the telehealth-based intervention delivery protocol to meet individual stroke survivors' needs to motivate and enhance their ADL performance.

Impact of Virtual Reality-Based Therapies on Cognition and Mental Health of Stroke Patients: Systematic Review and Meta-analysis

Background

Stroke remains one of the major chronic illnesses worldwide that health care organizations will need to address for the next several decades. Individuals poststroke are subject to levels of cognitive impairment and mental health problems. Virtual reality (VR)-based therapies are new technologies used for cognitive rehabilitation and the management of psychological outcomes.

Objective

This study performed a meta-analysis to evaluate the effects of VR-based therapies on cognitive function and mental health in patients with stroke.

Methods

A comprehensive database search was performed using PubMed, MEDLINE (Ovid), Embase, Cochrane Library, and APA PsycINFO databases for randomized controlled trials (RCTs) that studied the effects of VR on patients with stroke. We included trials published up to April 15, 2021, that fulfilled our inclusion and exclusion criteria. The literature was screened, data were extracted, and the methodological quality of the included trials was assessed. Meta-analysis was performed using RevMan 5.3 software.

Results

A total of 894 patients from 23 RCTs were included in our meta-analysis. Compared to traditional rehabilitation therapies, the executive function (standard mean difference [SMD]=0.88, 95% confidence interval [CI]=0.06-1.70, P=.03), memory (SMD=1.44, 95% CI=0.21-2.68, P=.02), and visuospatial function (SMD=0.78, 95% CI=0.23-1.33, P=.006) significantly improved among patients after VR intervention. However, there were no significant differences observed in global cognitive function, attention, verbal fluency, depression, and the quality of life (QoL).

Conclusions

The findings of our meta-analysis showed that VR-based therapies are efficacious in improving executive function, memory, and visuospatial function in patients with stroke. For global cognitive function, attention, verbal fluency, depression, and the QoL, further research is required.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42021252788; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=252788

Virtual Reality-Based Therapy Reduces the Disabling Impact of Fibromyalgia Syndrome in Women: Systematic Review with Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Virtual reality-based therapy (VRBT) is a novel therapeutic approach to be used in women with fibromyalgia syndrome (FMS). The aim of our study is to assess the effect of VRBT to reduce the impact of FMS in outcomes such as pain, dynamic balance, aerobic capacity, fatigue, quality of life (QoL), anxiety and depression.

METHODS

Systematic review with meta-analysis was conducted from a bibliographic search in PubMed, Scopus, PEDro, Web of Science and CINAHL until April 2021 in accordance with PRISMA guidelines. We included randomized controlled trials (RCTs) that compare VRBT versus others to assess the mentioned outcomes in women with FMS. Effect size was calculated with standardized mean difference (SMD) and its 95% confidence interval (95% CI).

RESULTS

Eleven RCTs involving 535 women with FMS were included. Using the PEDro scale, the mean methodological quality of the included studies was moderate (6.63 ± 0.51). Our findings showed an effect of VRBT on the impact of FMS (SMD -0.62, 95% CI -0.93 to -0.31); pain (SMD -0.45, 95% CI -0.69 to -0.21); dynamic balance (SMD -0.76, 95% CI -1.12 to -0.39); aerobic capacity (SMD 0.32, 95% CI 0.004 to 0.63); fatigue (SMD -0.58, 95% CI -1.02 to -0.14); QoL (SMD 0.55, 95% CI 0.3 to 0.81); anxiety (SMD -0.47, 95% CI -0.91 to -0.03) and depression (SMD -0.46, 95% CI -0.76 to -0.16).

CONCLUSIONS

VRBT is an effective therapy that reduces the impact of FMS, pain, fatigue, anxiety and depression and increases dynamic balance, aerobic capacity and quality of life in women with FMS. In addition, VRBT in combination with CTBTE showed a large effect in reducing the impact of FMS and fatigue and increasing QoL in these women.

Virtual reality and annotated radiological data as effective and motivating tools to help Social Sciences students learn neuroanatomy

Neuroanatomy as a subject is important to learn, because a good understanding of neuroanatomy supports the establishment of a correct diagnosis in neurological patients. However, rapid changes in curricula reduced time assigned to study (neuro)anatomy. Therefore, it is important to find alternative teaching methods to study the complex three-dimensional structure of the brain. The aim of this manuscript was to explore the effectiveness of Virtual Reality (VR) in comparison with Radiological Data (RaD) as suitable learning methods to build knowledge and increase motivation for learning neuroanatomy. Forty-seven students (mean age of 19.47 ± 0.54 years; 43 females; 4 males) were included; 23 students comprised the VR group. Both methods showed to improve knowledge significantly, the improvement between groups was not different. The RaD group showed to have a significantly higher score on expectancy than students in the VR group. Task value scores regarding finding a task interesting, useful and fun were found to be significantly different in favor of the VR group. Consequently, significant higher Motivation scores were found in the VR group. Motivation and expectancy, however, did not moderate learning results, whereas task value impacted the results in favour of the VR group. This study concludes that VR and RaD are effective and diverting methods to learn neuroanatomy, with VR being more motivating than RaD. Future research should investigate motivation and task value when using VR over a longer period of time.