A quantitative analysis of postural control in elderly patients with vestibular disorders using visual stimulation by virtual reality

Reliability of the Wii balance board for static and dynamic balance assessment in total knee arthroplasty patients

PURPOSE

Poor performance in practicing balance tasks is partly caused by the changes in the knee function and balance control activities following total knee arthroplasty (TKA). The purpose of this study was to determine the test-retest reliability of the static and dynamic balance measures using Wii Balance Board (WBB) in patients after TKA.

DESIGN

Thirty-one TKA patients (6 males, 27 females, mean age 55 ± 5.3 years) were involved in the study. They performed four standing balance trials on a WBB on two occasions, with an interval of 3-7 days apart. Double leg stance and functional reach task with opened and closed eyes were assessed in four trials. Extracted center of pressure (COP) measures collected included: mean velocity, medio-lateral displacement, antero-posterior displacement, and area. Intraclass correlation coefficients (ICC), standard error of measure (SEM), minimal detectable change (MDC) and Bland-Altman plots were calculated to show the reliability of COP measures.

RESULTS

ICCs ranged from 0.51 to 0.86 for the four trials indicating moderate-to-good reliability. Just the medio-lateral displacement in double leg open eyes condition showed weak reliability (ICC = 0.29). The highest and lowest ICC values (0.86, 0.29) were obtained for COP medio-lateral displacement in double leg open eyes condition and medio-lateral displacement in double leg close eyes condition measures, respectively. SEM (0.03-5.93) and MDC (0.09-16.45) range scores varied. Bland-Altman plots revealed no significant difference between two trials in both opened and closed eyed conditions, indicating strong agreement between assessments.

CONCLUSION

These findings suggest that the WBB was a reliable tool for assessing static and dynamic balance tests in TKA patients, making it as a suitable tool for standing balance assessment in clinical settings.

Exploring new balance and gait factors that are associated with osteosarcopenia in patients with a previous fall and/or fracture history

Osteosarcopenic individuals have poor muscle function and increased bone fragility, which results in a severe detriment to health outcomes. Hence, there is a necessity to discover easily accessible factors associated with osteosarcopenia to develop timely interventions. This study aimed to determine new sensitive balance and/or gait variables that are associated with osteosarcopenia in a population of older people with a history of falls and/or fractures. In a cross-sectional cohort study, 306 men and women aged ≥65 years completed a series of questionnaires, clinical assessments and muscle strength and function tests. Subsequently, participants were separated into osteopenia, osteoporosis and osteosarcopenia, groups for comparison and further analysis. Osteosarcopenia performed worse than osteopenia and osteoporosis in grip strength, gait speed, physical function scores and in multiple gait and balance indices (p<0.001). During posturography testing, there were larger elliptical areas with eyes open (p = 0.003), and eyes closed (p = 0.043) and increased sway velocity on a firm platform (p = 0.007) in the osteosarcopenia group, compared to osteoporosis. Limits of stability and eyes open ellipse area significantly contributed to the multivariable model (p = 0.029 and p = 0.038, respectively), suggesting that these balance parameters, along with grip strength, may be useful in identifying older adults with osteosarcopenia from those with only osteopenia/osteoporosis. Older adults with osteosarcopenia and a history of falls and/or fractures demonstrated inferior strength, function, and gait characteristics. This study identified indices of balance that were sensitive discriminators for osteosarcopenia and could be easily implemented into routine assessment.

Virtual reality-based interventions for the rehabilitation of vestibular and balance impairments post-concussion: a scoping review

BACKGROUND

Concussions and mild traumatic brain injuries are the most common causes of physical and cognitive disability worldwide. Concussion can result in post-injury vestibular and balance impairments that can present up to five years post initial concussion event, ultimately affecting many daily and functional activities. While current clinical treatment aims to reduce symptoms, the developing use of technology in everyday life has seen the emergence of virtual reality. Current literature has failed to identify substantial evidence regarding the use of virtual reality in rehabilitation. The primary aim of this scoping review is to identify, synthesise, and assess the quality of studies reporting on the effectiveness of virtual reality for the rehabilitation of vestibular and balance impairments post-concussion. Additionally, this review aims to summarise the volume of scientific literature and identify the knowledge gaps in current research pertaining to this topic.

METHODS

A scoping review of six databases (PubMed, Embase, CINAHL, ProQuest, SportDiscus, Scopus) and a grey literature (Google Scholar) was conducted using three key concepts (virtual reality, vestibular symptoms, and post-concussion). Data was charted from studies and outcomes were categorised into one of three categories: (1) balance; (2) gait; or (3) functional outcome measures. Critical appraisal of each study was conducted using the Joanna Briggs Institute checklists. A critical appraisal of each outcome measure was also completed utilising a modified GRADE appraisal tool to summarise the quality of evidence. Effectiveness was assessed using calculations of change in performance and change per exposure time.

RESULTS

Three randomised controlled trials, three quasi-experimental studies, three case studies, and one retrospective cohort study were ultimately included, using a thorough eligibility criteria. All studies were inclusive of different virtual reality interventions. The ten studies had a 10-year range and identified 19 different outcome measures.

CONCLUSION

The findings from this review suggests that virtual reality is an effective tool for the rehabilitation of vestibular and balance impairments post-concussion. Current literature shows sufficient but low level of evidence, and more research is necessary to develop a quantitative standard and to better understand appropriate dosage of virtual reality intervention.

Virtual Reality-A Supplement to Posturography or a Novel Balance Assessment Tool?

Virtual reality (VR) is a well-established technology in medicine. Head-mounted displays (HMDs) have made VR more accessible in many branches of medical research. However, its application in balance evaluation has been vague, and comprehensive literature on possible applications of VR in posture measurement is scarce. The aim of this review is to conduct a literature search on the application of immersive VR delivered using a head-mounted display in posturographic measurements. A systematic search of two databases, PubMed and Scopus, using the keywords "virtual reality" and "posturography," was performed following PRISMA guidelines for systematic reviews. Initial search results returned 89 non-duplicate records. Two reviewers independently screened the abstracts. Sixteen papers fulfilled the inclusion criteria and none of the exclusion criteria and were selected for complete text retrieval. An additional 16 records were identified from citation searching. Ultimately, 21 studies were included in this review. virtual reality is often used as additional visual stimuli in static and dynamic posturography evaluation. Only one study has attempted to evaluate a VR environment in a head-mounted display as an independent method in the assessment of posture. Further research should be conducted to assess HMD VR as a standalone posturography replacement.

Systematic Review and Meta-Analysis of the Application of Virtual Reality in Hearing Disorders

Background and Objectives

Trendy technologies, such as artificial intelligence, virtual reality (VR), and augmented reality (AR) are being increasingly used for hearing loss, tinnitus, and vestibular disease. Thus, we conducted this systematic review and meta-analysis to identify the possible benefits of the use of VR and AR technologies in patients with hearing loss, tinnitus, and/or vestibular dysfunction, with the aim of suggesting potential applications of these technologies for both researchers and clinicians.

Materials and Methods

Published articles from 1968 to 2022 were gathered from six electronic journal databases. Applying our specified inclusion and/or exclusion criteria, 23 studies were analyzed. As only one article on hearing loss and two articles on tinnitus were found, 20 studies on vestibular dysfunction were only finally included for the meta-analysis. Standardized mean differences (SMDs) were chosen as estimates to compare the studies. A funnel plot and Egger’s regression analysis were used to identify any risk of bias.

Results

High heterogeneity (I²: 83%, τ²: 0.5431, p<0.01) was identified across the studies on vestibular dysfunction. VR-based rehabilitation was significantly effective for individuals with vestibular disease (SMDs: 0.03, 95% confidence interval [CI]: -0.08 to 0.15, p<0.05). A subgroup analysis revealed that only improvement in the subjective questionnaire was meaningful and statistically significant (SMDs: -0.66, 95% CI: -1.10 to -0.22).

Conclusions

VR-based vestibular rehabilitation showed potential for subjective rating measures like Dizziness Handicap Index. The negative effect of aging on vestibular disease was indirectly confirmed. More clinical trials and an evidence-based approach are needed to confirm the implementation of state-of-the-art technology for hearing loss and tinnitus, representative diseases in neurotology.

Postural and Head Control Given Different Environmental Contexts

Virtual reality allows for testing of multisensory integration for balance using portable Head Mounted Displays (HMDs). HMDs provide head kinematics data while showing a moving scene when participants are not. Are HMDs useful to investigate postural control? We used an HMD to investigate postural sway and head kinematics changes in response to auditory and visual perturbations and whether this response varies by context. We tested 25 healthy adults, and a small sample of people with diverse monaural hearing (n = 7), or unilateral vestibular dysfunction (n = 7). Participants stood naturally on a stable force-plate and looked at 2 environments via the Oculus Rift (abstract "stars;" busy "street") with 3 visual and auditory levels (static, "low," "high"). We quantified medio-lateral (ML) and anterior-posterior (AP) postural sway path from the center-of-pressure data and ML, AP, pitch, yaw and roll head path from the headset. We found no difference between the different combinations of "low" and "high" visuals and sounds. We then combined all perturbations data into "dynamic" and compared it to the static level. The increase in path between "static" and "dynamic" was significantly larger in the city environment for: Postural sway ML, Head ML, AP, pitch and roll. The majority of the vestibular group moved more than controls, particularly around the head, when the scenes, especially the city, were dynamic. Several patients with monaural hearing performed similar to controls whereas others, particularly older participants, performed worse. In conclusion, responses to sensory perturbations are magnified around the head. Significant differences in performance between environments support the importance of context in sensory integration. Future studies should further investigate the sensitivity of head kinematics to diagnose vestibular disorders and the implications of aging with hearing loss to postural control. Balance assessment and rehabilitation should be conducted in different environmental contexts.

The Influence of Virtual Reality Head-Mounted Displays on Balance Outcomes and Training Paradigms: A Systematic Review

Background: Falls are the leading causes of (non)fatal injuries in older adults. Recent research has developed interventions that aim to improve balance in older adults using virtual reality (VR).

Purpose: We aimed to investigate the validity, reliability, safety, feasibility, and efficacy of head mounted display (HMD) systems for assessing and training balance in older adults.

Methods: We searched EBSCOhost, Scopus, Web of Science, and PubMed databases until 1 September 2020 to find studies that used HMD systems for assessing or training balance. The methodological quality was assessed using a modified version of Downs and Black. We also appraised the risk of bias using Risk of Bias Assessment tool for Non-randomized Studies (RoBANS).

Results: A total of 19 articles (637 participants) were included for review. Despite heterogenous age ranges and clinical conditions across studies, VR HMD systems were valid to assess balance and could be useful for fall prevention and for improving postural control and gait patterns. These systems also have the capacity to differentiate healthy and balance-impaired individuals. During VR versions of traditional balance tests, older adults generally acquire a cautious behavior and take more time to complete the tasks.

Conclusion: VR HMD systems can offer ecologically valid scenarios to assess and train functional balance and can be used alone or in addition to other interventions. New norms and protocols should be defined according to participants' age, health status, and severity of their illness when using VR HMD systems for balance assessment and training. For safe and feasible training, attention must be given to display type, VR elements and scenarios, duration of exposure, and system usability. Due to high risk of bias and overall poor quality of the studies, further research is needed on the effectiveness of HMD VR training in older adults.

The Use of Virtual Reality Through Head-Mounted Display on Balance and Gait in Older Adults: A Scoping Review

Introduction: Falls are the most prominent cause of injury and injury-related deaths among older adults (OAs). Virtual reality has been utilized as a method of improving balance and gait in OAs. However, the use of virtual reality through a head-mounted display (VR-HMD) in this area is limited. Objective: The objective of this scoping review was to identify research that used VR-HMD in relation to balance and gait in OAs and to evaluate how VR-HMD is being used with this population. Materials and Methods: A systematic search of the literature was carried out from June 2019 to July 2019 through the following databases: Scopus, Web of Science, PUBMED, and PsycInfo. Eligible studies involved the use of VR-HMD to assess or intervene in balance or gait outcomes of OAs (≥65 years). Articles were not limited to any specific study design or by the year of publication. Results: Our search identified 306 possible articles, of which eight citations met the eligibility criteria. Four studies utilized VR-HMD as an assessment tool or to perturb the balance, while the other four used VR-HMD in their interventions. Conclusions: Currently, it is not clear whether VR-HMD alone is an effective tool for improving balance and gait. However, this review suggests that it is feasible to use VR-HMD with OAs to affect balance and gait. More research is needed in this area, although there appears to be great potential in utilizing VR-HMD with OAs to improve balance outcomes.

Using Augmented Reality with Older Adults in the Community to Select Design Features for an Age-Friendly Park: A Pilot Study

Sedentary behavior is prevalent in older adults. Older adults often underutilize public parks for exercising because the parks do not support their needs and preferences. Engaging older adults on the redesign of parks may help promote active lifestyles. The objectives of this pilot study were to evaluate (1) the effects of wearing augmented reality (AR) and virtual reality (VR) glasses on balance; (2) the effects of different virtual walls separating the walking trail from the roadway on older adults' gait, and (3) the preferences of the participants regarding wall design and other features. The participants were ten older adults (68 ± 5 years) who lived within two miles from the park. Balance and gait were assessed using a force plate and an instrumented mat. It was feasible to use AR with older adults in the park to evaluate features for redesign. Motion sickness was not an issue when using AR glasses, but balance was affected when wearing VR goggles. The area of postural sway increased approximately 25% when wearing AR glasses, and it increased by close to 70% when wearing VR goggles compared to no glasses. This difference is clinically relevant; however, we did not have enough power to identify the differences as statistically significant because of the small sample size and large variability. Different walls did not significantly affect the participants' gait either because they did not alter the way they walked or because the holograms were insufficiently realistic to cause changes. The participants preferred a transparent wall rather than tall or short solid walls to separate the park from the roadway.

Weighting and reweighting of visual input via head mounted display given unilateral peripheral vestibular dysfunction

We translated a well-established laboratory paradigm to study sensory integration into a Head-Mounted-Display (HMD). In the current study, a group of 23 individuals with unilateral vestibular dysfunction and 16 age-matched controls observed moving spheres projected from the Oculus Rift. We confirmed increased visual weighting with an unstable surface and decreased visual weighting (i.e., reweighting) with increased visual amplitude. We did not observe significant differences in gains and phases between individuals with vestibular dysfunction and age-matched controls. The vestibular group increased sway in mid and high frequencies significantly more than controls with the change in surface or visual amplitude. Mild visual perturbations within HMDs carry the potential to become a useful portable assessment of postural control in individuals with vestibular disorders.