Improving motor performance in Parkinson’s disease: a preliminary study on the promising use of the computer assisted virtual reality environment (CAREN)

Fun and games: a scoping review of enjoyment and intensity assessment in studies of game-based interventions for gait rehabilitation in neurological disorders

PURPOSE

Exergames are used to promote gait rehabilitation in patients with neurological disorders because they are believed to heighten patient enjoyment and training intensity. This scoping review evaluated whether and how studies support these claims.

METHODS

A search for studies published up until October 2023 involving virtual reality or exergames for patients with neurological disorders (stroke, Parkinson's disease, multiple sclerosis, spinal cord injury) was conducted on PubMed and Scopus, with additional articles identified through backward and forward citation searching. Studies collecting gait measurements, with at least five participants and a control group were included. Data extracted were rationale, and whether participants' enjoyment of the intervention and training intensity were assessed.

RESULTS

1060 records were identified with 58 included in this review. There were 34 articles on stroke, 11 on multiple sclerosis, and 13 on Parkinson's disease. Participant enjoyment and greater training intensity were important rationales but were only evaluated in 12 and seven of the included studies, respectively.

CONCLUSION

Results highlight that participant enjoyment and heightened training intensity are commonly cited rationales for using exergames in gait rehabilitation, but these effects are assumed and not routinely measured or analysed. Greater consistency is needed in the design and execution of exergaming studies for neurological disorders.

Integrating virtual reality into multidisciplinary care for Parkinson's disease: A narrative review

Parkinson's disease (PD) is a neurodegenerative disorder characterized by both motor and non-motor symptoms, significantly impacting patients' functionality and quality of life. Clinical exercise, as part of a multidisciplinary approach, is gaining a crucial role in PD management. Goal-based exercises, combining physical activity with cognitive tasks, external feedback and cues, motor sequencing strategies and dual-tasking may enhance motor learning processes and guide physiotherapy programs.Virtual reality (VR) and exergaming have also emerged as promising tools in PD rehabilitation, offering challenging activities in multisensory environments. They provide intensive and repetitive training, augmented feedback, and tailored exercises in highly interactive and enriched environments. Clinical studies have presented promising results in people with PD, supported by neuroimaging studies showing distinct brain activation patterns post-VR training. However, heterogeneity in study design and lack of standardized characterization of VR systems hinder further application in PD rehabilitation.In this review, we appraise the distinguishing features between different VR systems, highlight VR-related motor and cognitive training in PD and explore how VR interventions are aligned with principles of neuroplasticity and motor learning in PD.

Coupling neurologic music therapy with immersive virtual reality to improve executive functions in individuals with Parkinson's disease: A Quasi-Randomized Clinical Trial

Introduction

Parkinson's disease (PD) is one the most common neurodegenerative movement disorder, leading to motor and non-motor symptoms, including deficits in executive functions (EF), memory, visuospatial abilities, and psychomotor speed. Current treatments are primarily symptomatic, involving pharmacological, surgical strategies. Neurologic Music Therapy (NMT) has gained recognition for its effectiveness in neurorehabilitation of PD patients and improving motor and cognitive domains, such as EF. This study combines NMT with the virtual reality (VR) platform Computer-Assisted Rehabilitation Environment (CAREN), offering customizable environments for rhythmic cue practice to provide an innovative approach to Parkinson's rehabilitation.

Methods

In our single-blind quasi-randomized controlled trial, forty patients were assigned to either an experimental group (EG = 20) or a control group (CG = 20). Both groups underwent two months of training with CAREN scenarios (three times a week for 24 sessions). The experimental group additionally received NMT applied to the selected scenarios. Participants were evaluated by a neuropsychologist at baseline and immediately after training.

Results

Intra-group analysis showed significant improvements in the EG for MOCA (p = 0.007), FAB (p = 0.008), Stroop Error (p = 0.003), Stroop Time (p < 0.001), and Visual Search (p < 0.001). The CG showed a significant difference only in Stroop Error (p = 0.02).

Conclusions

This pilot study is the first to combine NMT with CAREN in PD patients. Our findings suggest that NMT, within an immersive VR environment, effectively improves cognitive and EF in PD. Music structured within NMT techniques, coupled with advanced audio-visual feedback from VR, offers an innovative and potentially more effective approach for managing cognitive and executive deficits associated with PD.

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

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

Might patients with cerebellar ataxia benefit from the Computer Assisted Rehabilitation ENvironment (CAREN)? A pilot study focusing on gait and balance

Introduction: Ataxia is a neurological symptom that causes decreased balance, loss of coordination, and gait alterations. Innovative rehabilitation devices like virtual reality (VR) systems can provide task-oriented, repetitive and intensive training with multisensorial feedback, thus promoting neuroplastic processes. Among these VR technologies, the Computer Assisted Rehabilitation ENvironment (CAREN) associates a split belt treadmill on a 6-degrees of freedom platform with a 180° VR screen and a Vicon motion capture system to monitor patients' movements during training sessions. Methods: Eight patients affected by cerebellar ataxia were enrolled and received 20 sessions of CAREN training in addition to standard rehabilitation treatment. Each patient was evaluated at the beginning and at the end of the study with 3D gait analysis and clinical scales to assess balance, gait function and risk of falls. Results: We found improvements in kinematic, kinetic, and electromyographic parameters (as per pre-post- CAREN training), as well as in clinical outcomes, such as balance and risk of falls in ataxic patients. In addition, we found that trunk rotation improved, after CAREN intervention, approximating to the normative values. Discussion: Our results suggested that CAREN might be useful to improve specific biomechanical parameters of gait in ataxic patients.

Do patients with neurological disorders benefit from immersive virtual reality? A scoping review on the emerging use of the computer-assisted rehabilitation environment

INTRODUCTION

Virtual reality (VR) is an advanced technology that creates simulated environments and conditions. By offering the possibility of combining motor, cognitive, and well-being in conjunction with the potential to manipulate multi-sensorial features in a safe environment, VR has emerged as a promising powerful rehabilitation tool. Among advanced VR systems, various authors have highlighted promising effects in the rehabilitation of the computer-assisted rehabilitation environment (CAREN - Motekforce Link; Amsterdam, The Netherlands). In our scoping review, we aimed to map the existing evidence on the use of CAREN in the rehabilitation of neurological patients.

EVIDENCE ACQUISITION

This scoping review was conducted following the PRISMA guidelines. A search was carried out for all peer-reviewed articles published until June 30, 2023, using the following databases: PubMed, Embase, Cochrane Database, PeDro and Web of Science. The following terms have been used: ("Cognitive Rehabilitation" OR "Motor Rehabilitation" OR "CAREN" or "Computer-Assisted Rehabilitation Environment") AND ("Virtual Reality" OR "Rehab").

EVIDENCE SYNTHESIS

From the assessed studies, only seven met the inclusion criteria: 1) one study concerned cognitive rehabilitation in patients suffering from Parkinson's Disease (PD); 2) one was on the usability of CAREN in PD patients; 3) two studies related to the influence of emotional components to CAREN rehabilitation; 4) three studies were related to motor rehabilitation using CAREN, and involved individuals with PD, Multiple Sclerosis, TBI, respectively. Generally, the few assessed studies demonstrate that CAREN is a safe and potentially effective tool to treat different symptoms (including gait and vestibular disturbances, executive function, depressive mood, and anxiety) in patients with different neurological disorders.

CONCLUSIONS

The reviewed literature indicated the potential use of CAREN in improving motor and cognitive skills with conflicting results on emotional aspects. However, since the data comes from few and small sample size studies, further research is needed to confirm the effectiveness of the tool in neurorehabilitation.

The effects of augmented and virtual reality gait training on balance and gait in patients with Parkinson's disease

OBJECTIVE

Augmented reality (AR) and virtual reality (VR) facilitate motor learning by enabling the practice of task-specific activities in a rich environment. Therefore, AR and VR gait training may improve balance and gait in Parkinson's Disease (PD).

METHODS

Thirty patients with PD were randomly divided into study (n = 15) and control (n = 15) groups. The study group was given AR and VR gait training combined with conventional training. The control group was given conventional training only. The training was applied to both groups 3 days a week for 6 weeks. Motor symptoms with the Unified Parkinson Disease Rating Scale-Motor Examination (UPDRS-III), balance with posturography and Berg Balance Scale (BBS), perceived balance confidence with Activity-Specific Balance Confidence Scale (ABC), gait with spatio-temporal gait analysis, and functional mobility with Timed Up and Go Test (TUG) were assessed.

RESULTS

At the end of the study; UPDRS-III, posturography measurements, BBS, ABC, spatio-temporal gait parameters, and TUG improved in the study group (p < 0.05), while BBS, ABC, and only spatial gait parameters (except for step width) improved in the control group (p < 0.05). There was no change in posturography measurement, temporal gait parameters, and TUG in control group (p > 0.05). When the developed parameters in both groups were compared, the amount of improvement in BBS and ABC was found similar (p > 0.05), while the improvement in the other parameters was found higher in the study group (p < 0.05).

CONCLUSION

It was concluded that AR and VR gait training provides the opportunity to practice walking with different tasks in increasingly difficult environments, thus improving balance and walking by facilitating motor learning.

Effects of Virtual Reality in the Rehabilitation of Parkinson's Disease: A Systematic Review

BACKGROUND

Parkinson's disease is characterised by the loss of balance and the presence of walking difficulties. The inclusion of rehabilitation therapies to complement pharmacological therapy allows for comprehensive management of the disease. In recent years, virtual reality has been gaining importance in the treatment of neurological diseases and their associated symptoms. Therefore, the objective of this systematic review was to analyse the effectiveness of virtual reality on balance and gait in patients with Parkinson's disease.

METHODS

This study is a systematic review conducted following PRISMA's statements. An electronic search of the literature was carried out in the following databases: PubMed, Cochrane, Dialnet, Scopus, Web of Science, PsycINFO and Science Direct PEDro. The inclusion criteria were controlled and non-controlled clinical trials published in the last 12 years in English or Spanish, in which virtual reality was applied to treat balance and gait impairments in patients with Parkinson's disease.

RESULTS

20 studies were finally included in this review. A total of 480 patients participated in the included studies. All patients were diagnosed with Parkinson's disease. Most of the investigations used the Nintendo Wii + Balance Board or the Microsoft Kinect TM combined with the Kinect Adventures games as a virtual reality device.

CONCLUSIONS

According to the results of this literature review, virtual reality-based interventions achieve good adherence to treatment, bring innovation and motivation to rehabilitation, and provide feedback as well as cognitive and sensory stimulation in patients with Parkinson's disease. Therefore, virtual reality can be considered an alternative for personalised rehabilitation and for home treatment.

Survey of Movement Reproduction in Immersive Virtual Rehabilitation

Virtual reality (VR) has emerged as a powerful tool for rehabilitation. Many effective VR applications have been developed to support motor rehabilitation of people affected by motor issues. Movement reproduction, which transfers users' movements from the physical world to the virtual environment, is commonly used in VR rehabilitation applications. Three major components are required for movement reproduction in VR: (1) movement input, (2) movement representation, and (3) movement modulation. Until now, movement reproduction in virtual rehabilitation has not yet been systematically studied. This article aims to provide a state-of-the-art review on this subject by focusing on existing literature on immersive motor rehabilitation using VR. In this review, we provided in-depth discussions on the rehabilitation goals and outcomes, technology issues behind virtual rehabilitation, and user experience regarding movement reproduction. Similarly, we present good practices and highlight challenges and opportunities that can form constructive suggestions for the design and development of fit-for-purpose VR rehabilitation applications and can help frame future research directions for this emerging area that combines VR and health.

The effect of Computer Assisted Rehabilitation Environment (CAREN) in cognitive impairment and coping strategies in Parkinson's disease: a preliminary study

Parkinson's disease is a neurodegenerative disorder characterized by different motor, vegetative, behavioral, and cognitive impairments, with worsening quality of life. Virtual reality devices have given promising results in neurorehabilitation as they can provide multisensory stimulation in a realistic environment. This study aims to test the efficacy of virtual reality training by using Computer Assisted Rehabilitation Environment in cognitive impairment in a sample of PD. 31 patients affected by PD were enrolled. All PD patients underwent 24 sessions of Computer Assisted Rehabilitation Environment training. The participants were assessed at baseline (T0) and after two months (T1). Our results suggested that Computer Assisted Rehabilitation Environment training may be effective in the cognitive and emotional domains, particularly by improving executive function, anxiety, and depressive symptoms. These changes have helped to improve self-efficacy and coping strategies. These results indicate greater cognitive and physical effort to overcome stressors. Our results show that Computer Assisted Rehabilitation Environment training was beneficial in improving cognitive functions. Longer duration training may be especially beneficial for patients with mild cognitive impairment. Our findings open the door to tailored personalized treatments based on the patient's motor and cognitive profiles.

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.

Virtual reality for neurorehabilitation: A bibliometric analysis of knowledge structure and theme trends

Background

As an emerging technology, virtual reality (VR) has been broadly applied in the medical field, especially in neurorehabilitation. The growing application of VR therapy promotes an increasing amount of clinical studies. In this paper, we present a bibliometric analysis of the existing studies to reveal the current research hotspots and guide future research directions.

Methods

Articles and reviews on the related topic were retrieved from the Science Citation Index Expanded of Web of Science Core Collection database. VOSviewer and Citespace software were applied to systematically analyze information about publications, countries, institutions, authors, journals, citations, and keywords from the included studies.

Results

A total of 1,556 papers published between 1995 and 2021 were identified. The annual number of papers increased gradually over the past three decades, with a peak publication year in 2021 (n = 276). Countries and institutions from North America and Western European were playing leading roles in publications and total citations. Current hotspots were focused on the effectiveness of VR therapy in cognitive and upper limb motor rehabilitation. The clusters of keywords contained the four targeted neurological diseases of VR, while the burst keywords represented that the latest studies were directed toward more defined types of VR therapy and greater study design.

Conclusions

Our study offers information regarding to the current hotspots and emerging trends in the VR for rehabilitation field. It could guide future research and application of VR therapy in neurorehabilitation.

Effect of Immersive Virtual Reality by a Computer Assisted Rehabilitation Environment (CAREN) in Juvenile Huntington’s Disease: A Case Report

Various studies have proven the utility of immersive virtual reality (VR) as a complementary approach to conventional neurorehabilitation therapy for improving neuromuscular and cognitive outcomes in several neurological diseases. We hereby report findings from a single-case experience of a 21-year-old woman affected by juvenile Huntington’s disease (HD) who underwent a targeted rehabilitative approach using an advanced Computer Assisted Rehabilitation Environment (CAREN) with a three sessions/week schedule for six months. At the end of the program, a manifested improvement was noticed in the Falls Efficacy Scale International score, in the Tinetti Scale, in the Berg Balance score and in the lower limb strength (MRC scale). Minor although tangible improvements were also noticed in some physical performance tests (10 m walking test, time up and go test). Findings reported, although preliminary, extend for the first time the usefulness of neurorehabilitation using innovative VR technologies also to juvenile HD, a condition for which common rehabilitation strategies bring only marginal physical benefits in the majority of cases. Future, controlled studies are awaited for generalizing these observations to larger populations and for clarifying whether such benefits may persist also in the long-term.

Does cybersickness affect virtual reality training using the Computer Assisted Rehabilitation Environment (CAREN)? Preliminary results from a case-control study in Parkinson's disease

Introduction and objective: This pilot study aimed to evaluate whether and to what extent cybersickness (CS) may affect a rehabilitation program using the Computer-assisted Rehabilitation Environment (CAREN), a virtual reality (VR) computer-assisted device for clinical rehabilitation. Methods: The study was carried out on 30 subjects, 15 patients with Parkinson's Disease (PD) and 15 healthy controls (HC), which underwent a set of four exergames programmed by our team for PD rehabilitation training. Results: All participants completed the Motion Sickness Susceptibility Questionnaire Short-form (MSSQ) before the training and the Motion Symptoms Assessment Questionnaire (MSAQ) immediately after a single CAREN session. Overall, mean MSAQ scores remained low after the session, suggesting that the users did not experience severe discomfort. We found no significant difference in MSAQ scores between the two groups, while there was a statistically significant difference for the subsection of MSAQ regarding the peripheral symptoms (i.e. sweating, cold sweating, feeling warm), which were higher in HC. Moreover, the results highlighted some correlation between MSSQ and MSAQ. Gastrointestinal symptoms in PD, as well as MSSQ and sopite-related symptoms in HC, were also correlated with susceptibility to CS. Conclusions: As CS is rarely reported after CAREN, this and similar devices may be considered comfortable and safe for patients' rehabilitation involving VR training, including PD persons.

Does embodied cognition allow a better management of neurological diseases? A review on the link between cognitive language processing and motor function

Embodied cognition (EC) refers to the interplay occurring in thinking among individual's sensorimotor capacities (i.e., the ability of the body to respond to its senses with movement), the body itself, and the environment. The aim of the present narrative review is to provide an overall understanding of whether and how motor training could lead to language recovery, consistently with EC theories (action-perception cycle, mirror neuron systems -MNS-, and embodied semantics). We therefore reviewed the works dealing with EC in terms of the link between language processing, mirror neuron system (MNS), and motor function, evaluating the potential clinical implications for better managing neurological deficits. Connections between body and mind were found, as body states influence cognitive functions, such as perception and reasoning, as well as language processing, especially in neurological disorders. In fact, abnormalities in "embodied language" were found in movement disorders and neurodegenerative diseases, negatively affecting patients' rehabilitation outcomes. Understanding the link between language processing and motor outcomes is fundamental in the rehabilitation field, given that EC can be targeted to improve patients' functional recovery and quality of life.

Virtual Reality Based Cognitive Rehabilitation in Minimally Conscious State: A Case Report with EEG Findings and Systematic Literature Review

Chronic disorders of consciousness cause a total or partial and fluctuating unawareness of the surrounding environment. Virtual reality (VR) can be useful as a diagnostic and/or a neurorehabilitation tool, and its effects can be monitored by means of both clinical and electroencephalography (EEG) data recording of brain activity. We reported on the case of a 17-year-old patient with a disorder of consciousness (DoC) who was provided with VR training to improve her cognitive-behavioral outcomes, which were assessed using clinical scales (the Coma Recovery Scale-Revised, the Disability Rating Scale, and the Rancho Los Amigos Levels of Cognitive Functioning), as well as EEG recording, during VR training sessions. At the end of the training, significant improvements in both clinical and neurophysiological outcomes were achieved. Then, we carried out a systematic review of the literature to investigate the role of EEG and VR in the management of patients with DoC. A search on PubMed, Web of Science, Scopus, and Google Scholar databases was performed, using the keywords: "disorders of consciousness" and "virtual reality", or "EEG". The results of the literature review suggest that neurophysiological data in combination with VR could be useful in evaluating the reactions induced by different paradigms in DoC patients, helping in the differential diagnosis. In conclusion, the EEG plus VR approach used with our patient could be promising to define the most appropriate stimulation protocol, so as to promote a better personalization of the rehabilitation program. However, further clinical trials, as well as meta-analysis of the literature, are needed to be affirmative on the role of VR in patients with DoC.

Patients' perspective and usability of innovation technology in a new rehabilitation pathway: An exploratory study in patients with multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is an inflammatory neurodegenerative disease of the central nervous system, which causes sensori-motor and cognitive disabilities, as well as neuropsychiatric abnormalities. Technological innovations could offer a valuable way to improve neurorehabilitation outcomes. Aim of the study is to assess the feasibility and usability of new rehabilitation technologies as perceived by patients suffering from MS.

MATERIALS AND METHODS

MS inpatients attending the Robotic and Behavioral Neurorehabilitation Service of the IRCCS Centro Neurolesi Bonino Pulejo (Messina, Italy) from February 2017 to April 2019, were enrolled in this exploratory study. The patients were submitted to a personalized rehabilitation treatment using robotics (such as Lokomat, Geosystem, Ekso, Armeo) and virtual reality (i.e. BTS-Nirvana, CAREN, VRRS), following a dedicated innovative pathway.

RESULTS

All patients completed the study. Significant pre-post-treatment differences were found in the perception of patients' quality of life, regarding both physical and mental items (p<0,001), as well as in the achievement of the therapeutic goal. Finally, we observed that patients declared a high usability of the robotic devices, and that rehabilitation with the new devices was well tolerated.

CONCLUSIONS

our results support the idea that neurorehabilitation using innovation technologies can be useful for the commitment and motivation during the rehabilitation process, with possible positive effects on the functional and psychological outcomes of patients with MS.