Effect of video-based exergaming on arm and cognitive function in persons with multiple sclerosis: A randomized controlled trial

Effects of virtual reality-based rehabilitation on cognitive function and mood in multiple sclerosis: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Multiple sclerosis (MS) is a disabling neurological disease that causes cognitive impairment and mental problems that occur in all MS phenotypes but are most common in patients with secondary progressive MS. Various degrees of cognitive impairment and mental health concerns are common among patients with MS (PwMS). Virtual reality (VR)-based rehabilitation is an innovative approach aimed at enhancing cognitive function and mood in PwMS. This study aims to perform a meta-analysis to assess the effects of VR-based rehabilitation on cognitive function and mood in PwMS.

METHODS

Using PubMed, Embase, the Cochrane Library, Web of Science, and the Physiotherapy Evidence Database (PEDro), a thorough database search was performed to identify randomized controlled trials (RCTs) examining the effects of VR on PwMS. Trials published until October 31, 2023, that satisfied our predetermined inclusion and exclusion criteria were included. Data were extracted, literature was examined, and the methodological quality of the included trials was assessed. StataSE version 16 was used for the meta-analysis.

RESULTS

Our meta-analysis included 461 patients from 10 RCTs.

PRIMARY OUTCOMES

The Montreal Cognitive Assessment (MoCA) (weighted mean difference [WMD]=1.93, 95 % confidence interval [CI]=0.51-3.36, P = 0.008, I² = 75.4 %) the Spatial Recall Test (SPART) (WMD=3.57, 95 % CI=1.65-5.50, P < 0.001, I² = 0 %), immediate recall (standard mean difference [SMD]=0.37, 95 % CI=0.10-0.64, P = 0.007, I² = 0 %) and delayed recall ([SMD]=0.30, 95 % CI=0.06-0.54, P = 0.013, I² = 35.4 %) showed improvements in comparison to the control group in terms of global cognitive function immediate recall, delayed recall, and visuospatial abilities.

SECONDARY OUTCOMES

Compared to the control group, anxiety improved (standard mean difference [SMD]=0.36, 95 % CI=0.10-0.62, P = 0.007, I² = 43.1 %). However, there were no significant differences in processing speed, attention, working memory or depression.

CONCLUSIONS

This systematic review provides valuable evidence for improving cognitive function and mood in PwMS through VR-based rehabilitation. In the future, VR-based rehabilitation may be a potential method to treat cognitive function and emotional symptoms of MS.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO; identifier: CRD42023474467.

The effect of exercise on mental health and health-related quality of life in individuals with multiple sclerosis: A Systematic review and meta-analysis

BACKGROUND

A large body of evidence has tested the effect of exercise interventions on mental health and health-related quality of life (HRQoL) in individuals with multiple sclerosis (PwMS).

OBJECTIVE

To determine the effect of exercise interventions on mental health and HRQoL in PwMS.

METHODS

We searched four databases up to April 2023, and included randomized controlled trials that: 1) involved PwMS ≥18 years old; 2) delivered an exercise intervention; 3) measured subjective well-being, psychological well-being, social well-being, or HRQoL as outcomes. We reported standardized differences in means (d) with a 95 % confidence interval (CI), for continuous outcomes and an incidence rate ratio (IRR) with a 95 % CI for dichotomous outcomes.

RESULTS

Forty-nine studies (n = 2,057 participants) were included. Exercise improved overall well-being (d = 0.78; 95 % CI 0.483, 1.077; moderate certainty evidence), subjective well-being (d = 0.666; 95 % CI 0.405, 0.928; moderate certainty evidence), social well-being (d = 1.046; 95 % CI 0.569, 1.523; low certainty evidence), and HRQoL (d = 0.568; 95 % CI 0.396, 0.74; moderate certainty evidence).

CONCLUSION

Exercise interventions can improve well-being and HRQoL in PwMS. Future studies should focus on PwMS ≥ 65 years or with higher level of impairments.

Exercise-based gaming in patients with multiple sclerosis: A systematic review and meta-analysis

Background

Multiple sclerosis presents a significant burden, with balance disturbances impacting patients' daily living. Conventional therapies have been supplemented with technological advancements like virtual reality (VR) and exergaming, providing engaging, multisensory rehabilitation options.

Objective

This study aimed to synthesize evidence on exergaming's role in multiple sclerosis treatment, particularly to evaluate the impact of exergaming on cognitive, motor, and psychological outcomes in patients with multiple sclerosis.

Methods

A systematic review and subsequent meta-analysis design were employed. An extensive search was conducted up to June 2023 across five electronic databases - Web of Science, Scopus, PubMed, Cochrane, and EMBASE. The data extraction process from the selected studies was conducted independently. The risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool 1 (ROB1) and the National Institutes of Health (NIH) assessment tool. Continuous outcomes were consolidated as mean differences (MD) with 95% confidence intervals (CIs). Meta-analyses were performed using RevMan ver. 5.4.

Results

Out of 1,029 studies, 27 were included for meta-analysis. There were no significant differences in cognitive outcomes between the exergaming and the no-intervention group or the Conventional Physiotherapy and Rehabilitation interventions (CPRh) subgroups. However, the Symbol Digit Modalities Test (SDMT) showed a statistically significant difference in favor of exergaming in the no-intervention subgroup (MD = 5.40, 95% CI [0.08, 10.72], p = 0.05). In motor outcomes, exergaming only demonstrated better results in the 6-minute walking test compared to the no-intervention group (MD = 25.53, 95% CI [6.87, 44.19], p = 0.007). The Berg Balance Scale score in both studied subgroups and the Timed Up and Go (TUG) test in the no-intervention group favored exergaming. In terms of psychological outcomes, the Beck Depression Inventory did not reveal any significant differences, while the Modified Fatigue Impact Scale (MFIS) score favored exergaming in the CPRh subgroup.

Conclusion

Exergaming shows promise for enhancing cognitive and motor functions, motivation, adherence, and quality of life in MS patients, which is beneficial for nurses. It can be tailored to individual preferences and easily conducted at home, potentially serving as a viable alternative to traditional rehab programs, especially during relapses. However, further research is necessary to fully understand its optimal and lasting benefits.

Aerobic physical exercise versus dual-task cognitive walking in cognitive rehabilitation of people with stroke: a randomized clinical trial

Introduction

Stroke is a neurological deficit caused by an acute focal injury to the central nervous system due to vascular injury that can result in loss of neurological function, lasting brain damage, long-term disability and, in some cases, death. The literature reports that aerobic physical exercise, as well as dual-task cognitive walking, are used for the cognitive recovery of people with stroke. We aimed to assess whether aerobic physical exercise influences post-stroke cognitive recovery, namely performance on selective and sustained attention. We tested the hypothesis that post-stroke aerobic physical exercise leads to more significant gains than post-stroke dual-task cognitive walking.

Methods

We used a Randomized Clinical Trial, single-blind, parallel group, to verify the existence of differences between two groups. A total of 34 patients with subacute to chronic stroke were divided into two groups to train three times a week for 12 weeks: the aerobic physical exercise (PE) group engaged in 20 min on a treadmill, 20 min on a stationary bicycle and 5 min on a desk bike pedal exerciser per session; the dual-task (DT) gait exercise group walked for 45 min while simultaneously performing cognitive tasks per session. All participants were assessed on cognitive functioning with the Mini-Mental State Examination (MMSE) and d2 Test of Attention before acute interventions and post interventions. We have also applied a Visual Analog Scale to monitor the participants' perceived difficulty, pre-, post-acute, and post-chronic interventions. Participants also responded to a Borg Scale of perceived exertion following the acute and the final session of chronic training.

Results

A mixed model ANOVA revealed a significant interaction effect with a large effect size for most of the cognitive variables under study. The variables associated with the d2 Test of Attention showed significant differences between the groups, mainly from T0 to T2. Also for MMSE, an ANOVA revealed a significant interaction effect with significant improvements from T0 to T2. Our results strongly suggest that aerobic physical exercise is more beneficial than dual-task cognitive-gait exercise since in the PE group, cognitive attention scores increase, and cognitive impairment and perception of exertion decrease, compared to the DT group.

Conclusion

These findings support that PE provides more significant benefits for patients post-stroke when compared to DT.

Effect of different types of exercise on fitness in people with multiple sclerosis: A network meta-analysis

BACKGROUND

It is assumed that people with multiple sclerosis (MS) who participate in programs of physical exercise improve their physical fitness.

OBJECTIVE

The aim of this network meta-analysis (NMA) was to analyze the effect of different types of exercise on muscular fitness and cardiorespiratory fitness (CRF) among people with MS and to determine the best type of exercise according to disease severity.

METHODS

MEDLINE, the Physiotherapy Evidence Database, the Cochrane Library, SPORTDiscus, Scopus, and Web of Science were searched from inception to April 2022 to identify randomized controlled trials (RCTs) concerning the effect of physical exercise on fitness in people with MS. We ranked the types of physical exercise by calculating the surface under the cumulative ranking (SUCRA).

RESULTS

We included 72 RCTs involving 2543 MS patients in this NMA. A ranking of five types of physical exercise (aerobic, resistance, combined [aerobic and resistance], sensorimotor training, and mind-body exercises) was achieved. Combined and resistance training had the highest effect sizes (0.94, 95% CI 0.47, 1.41, and 0.93, 95% CI 0.57, 1.29, respectively) and the highest SUCRA (86.2% and 87.0%, respectively) for muscular fitness. The highest effect size (0.66, 95% CI 0.34, 0.99) and SUCRA (86.9%) for CRF was for aerobic exercise.

CONCLUSIONS

Combined and resistance training seem to be the most effective exercises to improve muscular fitness and aerobic exercise for CRF in people with MS.

The correlation between 9-HPT and patient-reported measures of upper limb function in multiple sclerosis: a systematic review and meta-analysis

Upper limb function is one of the most affected domains in people with multiple sclerosis (PwMS), as self-reported by 50% of patients. Heterogeneous results have been found about the correlation between objective and subjective upper limb function. The aim of the present study is to perform a systematic review and meta-analysis of studies presenting data on the strength of association between the gold standard for 9-Hole Peg Test scores and Patient-Reported Outcome Measures (PROMs) of manual ability. Primary research studies including assessments of 9-Hole Peg Test scores and Patient-Reported Outcome Measures were searched in Scopus, Web of Science, and PubMed. Meta analytical calculations were performed using a random-effects model. We retrieved n = 27 studies including n = 75 distinct effect sizes (N of subjects = 3263). The central tendency analysis showed a strong correlation between 9-HPT scores and PROMs (r = 0.51, 95% CI [0.44, 0.58]). Moderator analysis showed the effect size to be significantly larger in studies with a mean or median EDSS level indicating severe disability. The publication bias hypothesis was not supported; instead, we noted that studies based on larger samples also tend to report stronger effect sizes. Results of the study indicate that the correlation between 9-HPT and PROMs is strong, although the constructs measured by these instrument does not fully overlap. The correlation between 9-HPT and PROMs was stronger in larger studies and when samples include a sizeable subgroup of PwMS with severe disability, pointing out the importance of sample diversity.

Comparing virtual reality exergaming with conventional exercise in rehabilitation of people with multiple sclerosis: A systematic review

This systematic review aimed to present the comparison of the impacts of conventional exercise and virtual reality (VR) exergaming on the physical and cognitive abilities of people with multiple sclerosis (PwMS). The literature search was conducted in the EMBASE, PubMed, Scopus, CINAHL, and Cochrane Library databases. Eligible studies were identified by independent reviewers based on the title, abstract and full-texts. Studies were limited to randomized clinical trials published in peer-reviewed journals in English that compared conventional exercise with VR-exergaming for improving the physical and cognitive abilities of PwMS. Selected studies were assessed for their risk of bias and the major findings of the reviewed studies were analyzed descriptively. The search identified 239 articles of which 10 studies met the eligibility criteria. Despite these studies employing strategies to control biases, some risks of bias remain. Various gaming platforms and conventional exercises were used based on the extent of technologies and therapy regimens. The selected studies used measures of physical and cognitive abilities to compare VR-exergaming with conventional exercise. This review suggests positive impacts of both VR-exergaming and conventional exercise in MS rehabilitation. We also found that VR-exergaming generally exceeded conventional exercise for improving physical and cognitive abilities, psychosocial status, and fatigue.

Effect of web-implemented exercise interventions on depression and anxiety in patients with neurological disorders: a systematic review and meta-analysis

Introduction

Web-implemented exercise intervention is the latest and innovative method to improve people's mental health. Currently, many studies have proven that web-implemented interventions are effective to improve depression and anxiety in adults. However, the influence of different web-implemented exercise interventions on depression and anxiety in patients with neurological disorders is still unclear.

Objective

The study aims to systematically summarize the type and content of web-implemented exercise interventions and quantify the effect of different web-implemented exercise interventions on depression and anxiety in patients with neurological disorders.

Methods

Four literature databases (PubMed, Web of Science, China National Knowledge Infrastructure, and WanFang data) were searched. The literature search considered studies published in English or Chinese before October 13, 2022. Randomized controlled trials (RCTs) that participants accepted web-implemented interventions were included. Two authors independently extracted data and assessed the risk of bias for included studies. Standardized mean differences (SMD) with 95% CI were used to integrate the effect size.

Results

16 RCTs (a total of 963 participants) were included. The results showed that web-implemented exercise intervention had a significant effect on depression (SMD = -0.80; 95% CI, -1.09 to -0.52; I2 = 75%; P < 0.00001) and anxiety (SMD = -0.80; 95% CI, -1.23 to -0.36; I2 = 75%; P = 0.0003) in patients with a neurological disorder. The subgroup analysis showed that the effectiveness of the web-implemented exercise intervention was influenced by several factors, such as web-implemented exercise intervention type, component, and intervention duration.

Conclusion

Web-implemented exercise intervention has a relieving effect on depression and anxiety symptoms in patients with neurological disorders. Additionally, the intervention type, intervention duration, and component can influence the effect size.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42023409538.

Virtual reality-based therapy improves balance and reduces fear of falling in patients with multiple sclerosis. a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aims to conduct a meta-analysis to assess the effect of virtual reality-based therapy (VRBT) on balance dimensions and fear of falling in patients with multiple sclerosis (PwMS). Secondarily, to determine the most recommendable dose of VRBT to improve balance.

METHODS

PubMed Medline, Web of Science, Scopus, CINAHL and PEDro were screened, without publication date restrictions, until September 30th, 2021. Randomized controlled trials (RCTs) comparing the effectiveness of VRBT against other interventions in PwMS were included. Functional and dynamic balance, confidence of balance, postural control in posturography, fear of falling and gait speed were the variables assessed. A meta-analysis was performed by pooling the Cohen's standardized mean difference (SMD) with 95% confidence interval (95% CI) using Comprehensive Meta-Analysis 3.0.

RESULTS

Nineteen RCTs, reporting 858 PwMS, were included. Our findings reported that VRBT is effective in improving functional balance (SMD = 0.8; 95%CI 0.47 to 1.14; p < 0.001); dynamic balance (SMD = - 0.3; 95%CI - 0.48 to - 0.11; p = 0.002); postural control with posturography (SMD = - 0.54; 95%CI - 0.99 to - 0.1; p = 0.017); confidence of balance (SMD = 0.43; 95%CI 0.15 to 0.71; p = 0.003); and in reducing fear of falling (SMD = - 1.04; 95%CI - 2 to - 0.07; p = 0.035); but not on gait speed (SMD = - 0.11; 95%CI: - 0.35 to 0.14; p = 0.4). Besides, the most adequate dose of VRBT to achieve the greatest improvement in functional balance was at least 40 sessions, five sessions per week and 40-45 min per sessions; and for dynamic balance, it would be between 8 and 19 weeks, twice a week and 20-30 min per session.

CONCLUSION

VRBT may have a short-term beneficial role in improving balance and reducing fear of falling in PwMS.

The effect of exercise on cognitive function in people with multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

A growing body of research examining the effect of exercise on cognitive function in people with multiple sclerosis (MS), while findings of available studies were conflicting. We aimed to explore the effect of exercise on cognitive function in MS patients.

METHODS

For this systematic review and meta-analysis, we searched PubMed, Web of Science, EBSCO, Cochrane, and Scopus electronic databases, through July 18, 2022. Cochrane risk assessment tool was used to evaluate the methodological quality of the included literature.

RESULTS

Twenty-one studies with a total of 23 experimental groups and 21 control groups met the inclusion criteria. There was a significant effect of exercise on improving cognitive function in MS patients, while the effect size was small (Cohen's d = 0.20, 95% CI 0.06-0.34, p < 0.001, I² = 39.31%). Subgroup analysis showed that exercise significantly improved memory (Cohen's d = 0.17, 95% CI 0.02-0.33, p = 0.03, I² = 7.59%). In addition, multicomponent training, exercise conducted 8 weeks and 10 weeks, up to 60 min per session, 3 times or more per week, 180 min or more per week increased cognitive function significantly. Furthermore, a worse basal MS status (defined by the Expanded Disability Status Scale) and an older age were associated with greater improvement in cognitive function.

CONCLUSION

MS patients are recommended to participate in at least three multicomponent training sessions per week, with each session lasting up to 60 min, and the exercise goal of 180 min per week can be achieved by increasing the frequency of exercise. Exercise lasting 8 or 10 weeks is best for cognitive function improvement. Additionally, a worse basal MS status, or the older the age, the greater effect on cognitive function.

The Influence of Conventional and Innovative Rehabilitation Methods on Brain Plasticity Induction in Patients with Multiple Sclerosis

Physical rehabilitation and physical activity are known non-pharmacological methods of treating multiple sclerosis. Both lead to an improvement in physical fitness in patients with movement deficits while improving cognitive function and coordination. These changes occur through the induction of brain plasticity. This review presents the basics of the induction of brain plasticity in response to physical rehabilitation. It also analyzes the latest literature evaluating the impact of traditional physical rehabilitation methods, as well as innovative virtual reality-based rehabilitation methods, on the induction of brain plasticity in patients with multiple sclerosis.

Patient and Clinician Perspectives of Physical Therapy for Walking Difficulties in Multiple Sclerosis

Gait speed is frequently the primary efficacy endpoint in clinical trials of interventions targeting mobility in people with multiple sclerosis (MS). However, it is unclear whether increased gait speed is a meaningful outcome for people living with MS. The purpose of this study was to identify the most important aspects of mobility for people with MS and physical therapists and to explore how patients and clinicians perceive whether physical therapy has been effective. Forty-six people with MS and 23 physical therapy clinicians participated in a focus group, one-on-one interview, or electronic survey. The focus group and interview data were transcribed and coded to identify themes. Free-text survey responses were also coded, and multiple-choice options were analyzed for frequency. Among people with MS, falls and difficulties getting out into the community were identified as highly important mobility limitations. Clinicians also identified falls and safety as a priority. Walking speed was infrequently described as a problem, and although gait speed is often measured by clinicians, improving gait speed is rarely a treatment goal. Despite their emphasis on safety, clinicians lacked certainty about how to objectively measure improvements in safety. People with MS evaluated physical therapy effectiveness based on the ease by which they can do things and acknowledged that "not getting worse" is a positive outcome. Clinicians evaluated effectiveness based on the amount of change in objective outcome measures and by patient and caregiver reports of improved function. These findings indicate that gait speed is not of major importance to people with MS or physical therapy clinicians. People with MS want to be able to walk further and without an assistive device, and they want to avoid falls. Clinicians want to maximize safety while improving functional ability. Clinicians and patients may differ in their expected outcomes from physical therapy.

Digital Intervention For The Management Of Alzheimer's Disease

Alzheimer's disease (AD) is a progressive, multifactorial, chronic, neurodegenerative disease with high prevalence and limited therapeutic options, making it a global health crisis. Being the most common cause of dementia, AD erodes the cognitive, functional, and social abilities of the individual and causes escalating medical and psychosocial needs. As yet, this disorder has no cure and current treatment options are palliative in nature. There is an urgent need for novel therapy to address this pressing challenge. Digital therapeutics (Dtx) is one such novel therapy that is gaining popularity globally. Dtx provides evidence based therapeutic interventions driven by internet and software, employing tools such as mobile devices, computers, videogames, apps, sensors, virtual reality aiding in the prevention, management, and treatment of ailments like neurological abnormalities and chronic diseases. Dtx acts as a supportive tool for the optimization of patient care, individualized treatment and improved health outcomes. Dtx uses visual, sound and other non-invasive approaches for instance-consistent therapy, reminiscence therapy, computerised cognitive training, semantic and phonological assistance devices, wearables and computer-assisted rehabilitation environment to find applications in Alzheimer's disease for improving memory, cognition, functional abilities and managing motor symptom. A few of the Dtx-based tools employed in AD include "Memory Matters", "AlzSense", "Alzheimer Assistant", "smart robotic dog", "Immersive virtual reality (iVR)" and the most current gamma stimulation. The purpose of this review is to summarize the current trends in digital health in AD and explore the benefits, challenges, and impediments of using Dtx as an adjunctive therapy for the management of AD.

Participant characteristics of existing exercise studies in persons with multiple sclerosis - A systematic review identifying literature gaps

BACKGROUND

Exercise is a cornerstone in rehabilitation of persons with multiple sclerosis (pwMS), which is known to elicit beneficial effects on various symptoms and to have a potential disease-modifying effect. However, it remains to be elucidated if the existing MS exercise literature covers the full age and disability span of pwMS.

OBJECTIVE

To systematically review MS exercise studies and provide a detailed mapping of the demographic and clinical characteristics of the included pwMS.

METHODS

A systematic review of MS exercise studies were performed using MEDLINE and EMBASE. From the resulting MS exercise studies, mean sample characteristics were extracted.

RESULTS

4576 records were identified, from which 202 studies were included. Of these, 166 studies (82.2%) enrolled pwMS aged 35-54 years, 10.9% enrolled pwMS <35 years, and 6.9% enrolled pwMS ≥55 years (only 1.5% enrolled pwMS ≥60 years). A total of 118 studies (58.4%) reported Expanded Disability Status Scale (EDSS), with 88.1% of included pwMS having an EDSS between 2.0 and 6.5, while only one study enrolled pwMS with an EDSS ≥7.0. Finally, 80% of the studies included pwMS having a disease duration of 5-14.5 years.

CONCLUSION

Exercise studies in pwMS included primarily middle-aged (35-54 years) pwMS having an EDSS of 2.0-6.5 and a disease duration of 5-14.5 years. Few exercise studies were identified in young and older pwMS, in pwMS with mild disability and severe disability, and in pwMS having shorter or longer disease durations. These findings highlight the need for further investigation of exercise in these specific subgroups of pwMS as benefits of exercise might not generalize across subpopulations.

The effect of therapeutic exercise on depressive symptoms in people with multiple sclerosis - A systematic review

BACKGROUND

The prevalence of depressive symptoms in people with Multiple Sclerosis (MS) is around 25 - 50% and affects their daily life and general quality of life. Several studies investigating therapeutic exercise have shown highly beneficial effects in preventing or reducing depressive symptoms. The present systematic review was conducted to investigate randomized controlled trials on the effectiveness of therapeutic exercise programs on depressive symptoms in people with MS.

METHODS

A search was performed in PubMed, Scopus, APA Psychnet and ResearchGate. The keywords used were: therapeutic exercise, physiotherapy, physiotherapy, physical therapy, rehabilitation, depression, depressive disorders and multiple sclerosis. In addition, specific inclusion and exclusion criteria were set and the study selection process was conducted by two separate reviewers. The quality of the final studies included in the systematic review was assessed using the PEDro scale.

RESULTS

Out of the total of 934 studies initially identified, 9 studies were finally included. The results showed that physiotherapy interventions, through aerobic exercise, robotic-assisted gait training with or without virtual reality, aerobic exercise combined with Pilates, interval training, video-games and finally clinical Pilates, improve patients' depression and in many cases with much better results compared to classic physiotherapy type interventions.

CONCLUSION

The effect of therapeutic exercise has a positive impact on the depressive symptoms of people with MS. However, future research in this field is necessary to find the most proven curative forms to reduce depressive symptoms and improve the daily life of these patients.

Adjuvant Therapy for Attention in Children with ADHD Using Game-Type Digital Therapy

Children diagnosed with attention deficit hyperactivity disorder (ADHD) require early intervention and sustained treatment. This study used a game-based digital treatment planning NeuroWorld DTx to analyze the impact on attention and cognitive function in children with ADHD. Thirty children diagnosed with ADHD were recruited and subjected to a four-week NeuroWorld DTx digital treatment. To assess the impact of the digital therapeutic therapy on children's attention, we used the comprehension attention test (CAT) and Korean ADHD Rating Scale (K-ARS). Clinical global impression (CGI) and the Korean-child behavior checklist (K-CBCL 6-18) were used to examine the degree of improvement in ADHD. After four weeks, significant differences in the sensitivity and response style indices were noted, as compared with the baseline in the CAT test; in the case of K-ARS and CGI, a moderate decrease in ADHD was confirmed. The study achieved better results for the "total behavior problems" belonging to the K-CBCL assessment. Game-based digital therapy intervention can be a treatment method that elicits interest and satisfaction in children with ADHD and can be used as an adjunct to drug therapy to improve the quality of life and strengthen attention in children with symptoms of ADHD.

Non-Pharmacological Treatments of Cognitive Impairment in Multiple Sclerosis: A Review

Cognitive impairment (CI) represents a common symptom in patients suffering from multiple sclerosis (MS), which can affect every stage of the disease course. Recent studies seem to support cognitive rehabilitation (CR) for minimizing the CI consequences. We reviewed the currently available evidence on the non-pharmacological approaches to CI, with the aim of giving an overview of the treatments used worldwide, from the traditional methods to the most recent techniques. A search of the literature was conducted on PubMed (articles in English performed in the last five years on humans). A total of 37 articles met our eligibility criteria after screening titles, abstracts and full-text and were divided into three main groups: in-presence interventions; studies performed via tele-rehabilitation and miscellaneous. Despite the great heterogeneity of the intervention and assessment methods, the evidence suggests that a non-pharmacological approach can improve MS-related CI. Cognitive rehabilitation seems effective and well established, as well as the use of computerized CR having the benefit of being even more appealing. Limited conclusions can be drawn on group CR due to the small number of studies focused on this kind of intervention. Some of the innovative approaches (virtual reality, EEG-based neurofeedback, brain stimulation, exercise, diet modification) may play a role in future studies and should be deeply explored.

Active Videogaming Interventions in Adults with Neuromuscular Conditions: A Scoping Review

This review synthesized active videogaming (AVG) intervention literature over a 10-year period (2010-2020) for people with neuromuscular conditions (18-64 years of age), examining interventions that aimed to improve health and secondary conditions, physical activity, and outcomes quality of life (QOL). Systematic searches yielded 40 eligible studies. The major groups were multiple sclerosis (40%) and stroke (33%), and the study participants had mostly mild-to-moderate disability who were able to play games in a standing position. Research designs primarily involved randomized controlled trials (65%) and pre/post-trial design without a control group (28%). The majority of interventions used commercial off-the-shelf gaming systems, such as Nintendo Wii and Microsoft Kinect. Studies reported significant improvements in health outcomes, specifically in balance (n = 30/36), mobility (n = 24/27), and cardiorespiratory fitness (n = 6/8). Positive changes were also seen in secondary conditions (n = 8/12), physical activity (n = 3/4), and QOL outcomes (n = 8/16). AVG research for people with neuromuscular conditions has grown in both quantity and quality but several gaps remain. Study findings provide a roadmap for future AVG trials on understudied populations, and highlight technology and targeted outcomes as drivers of future intervention research.

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis

BACKGROUND

Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings.

OBJECTIVE

This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine "Google Scholar," and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games).

RESULTS

From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003).

CONCLUSIONS

Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969.

The Effect of Video Game-Based Interventions on Performance and Cognitive Function in Older Adults: Bayesian Network Meta-analysis

Background

The decline in performance of older people includes balance function, physical function, and fear of falling and depression. General cognitive function decline is described in terms of processing speed, working memory, attention, and executive functioning, and video game interventions may be effective.

Objective

This study evaluates the effect of video game interventions on performance and cognitive function in older participants in terms of 6 indicators: balance function, executive function, general cognitive function, physical function, processing speed, and fear of falling and depression.

Methods

Electronic databases were searched for studies from inception to June 30, 2020. Randomized controlled trials and case-controlled trials comparing video game interventions versus nonvideo game control in terms of performance and cognitive function outcomes were incorporated into a Bayesian network meta-analysis. All data were continuous variables.

Results

In total, 47 studies (3244 participants) were included. In pairwise meta-analysis, compared with nonvideo game control, video game interventions improved processing speed, general cognitive function, and depression scores. In the Bayesian network meta-analysis, interventions with video games improved balance function time (standardized mean difference [SMD] –3.34, 95% credible interval [CrI] –5.54 to –2.56), the cognitive function score (SMD 1.23, 95% CrI 0.82-1.86), processing speed time (SMD –0.29, 95% CrI –0.49 to –0.08), and processing speed number (SMD 0.72, 95% CrI 0.36-1.09), similar to the pairwise meta-analysis. Interventions with video games with strong visual senses and good interactivity ranked first, and these might be more beneficial for the elderly.

Conclusions

Our comprehensive Bayesian network meta-analysis provides evidence that video game interventions could be considered for the elderly for improving performance and cognitive function, especially general cognitive scores and processing speed. Games with better interactivity and visual stimulation have better curative effects. Based on the available evidence, we recommend video game interventions for the elderly.

Trial Registration

PROSPERO CRD42020197158; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197158

Virtual Reality-Based Therapy Improves Fatigue, Impact, and Quality of Life in Patients with Multiple Sclerosis. A Systematic Review with a Meta-Analysis

Patients with multiple sclerosis (PwMS) have a high level of fatigue and a reduced quality of life (QoL) due to the impact of multiple sclerosis (MS). Virtual reality-based therapy (VRBT) is being used to reduce disability in PwMS. The aim of this study was to assess the effect of VRBT on fatigue, the impact of MS, and QoL in PwMS. Methods: A systematic review with meta-analysis was conducted through a bibliographic search on PubMed, Scopus, Web of Science, and PEDro up to April 2021. We included randomized controlled trials (RCTs) with PwMS that received VRBT in comparison to conventional therapy (CT) including physiotherapy, balance and strength exercises, and stretching or physical activity, among others; or in comparison to simple observation; in order to assess fatigue, MS-impact, and QoL. The effect size was calculated using Cohen’s standardized mean difference with a 95% confidence interval (95% CI). Results: Twelve RCTs that provided data from 606 PwMS (42.83 ± 6.86 years old and 70% women) were included. The methodological quality mean, according to the PEDro Scale, was 5.83 ± 0.83 points. Our global findings showed that VRBT is effective at reducing fatigue (SMD −0.33; 95% CI −0.61, −0.06), lowering the impact of MS (SMD −0.3; 95% CI −0.55, −0.04), and increasing overall QoL (0.5; 95% CI 0.23, 0.76). Subgroup analysis showed the following: (1) VRBT is better than CT at reducing fatigue (SMD −0.4; 95% CI −0.7, −0.11), as well as in improving the mental dimension of QoL (SMD 0.51; 95% CI 0.02, 1); (2) VRBT is better than simple observation at reducing the impact of MS (SMD −0.61; 95% CI −0.97, −0.23) and increasing overall QoL (SMD 0.79; 95% CI 0.3, 1.28); and (3) when combined with CT, VRBT is more effective than CT in improving the global (SMD 0.6, 95% CI 0.13, 1.07), physical (SMD 0.87; 95% CI 0.3, 1.43), and mental dimensions (SMD 0.6; 95% CI 0.08, 1.11) of QoL. Conclusion: VRBT is effective at reducing fatigue and MS impact and improving QoL in PwMS.

Effect of Exercise on Fatigue in Multiple Sclerosis: A Network Meta-analysis Comparing Different Types of Exercise

OBJECTIVE

A network meta-analysis (NMA) of current evidence was conducted to determine if physical exercise has a positive influence on multiple sclerosis (MS) fatigue and type of exercise with the largest effect on fatigue also according to disease severity.

DATA SOURCES

MEDLINE, Embase, SPORTDiscus, Physiotherapy Evidence Database, Cochrane Library, and Web of Science. The search strategy combined relevant terms related to (1) MS; (2) clinical trials; (3) exercise; and (4) fatigue from inception to February 2021.

STUDY SELECTION

Randomized controlled trials concerning the effectiveness of different types of exercise on total and physical fatigue in people with MS were included.

DATA EXTRACTION

The data were extracted into predesigned data extraction tables. Risk of bias was evaluated with the Cochrane Risk of Bias tool (RoB 2.0), and the Grading of Recommendations, Assessment, Development, and Evaluation tool was used to evaluate the quality of the evidence.

DATA SYNTHESIS

A total of 58 studies were examined. Data were pooled using a random-effects model. A ranking of 7 and 8 different exercise interventions for physical and total fatigue scores, respectively, was achieved. The highest effects for pairwise comparisons were for combined exercise and resistance training vs control (ranging between -0.74 and -1.24). In the NMA, combined exercise (-1.51; 95% confidence interval [CI], -2.01 to -1.01) and resistance training (-1.15; 95% CI, -1.81 to -0.49) compared with the control group achieved the highest effects for physical and total fatigue, respectively.

CONCLUSIONS

Exercise should be considered an effective fatigue management strategy. Among the different exercise modalities, combined exercise is the most effective exercise modality for improving both physical and total fatigue. Resistance training is also an effective exercise for total fatigue among people diagnosed with MS.

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis (Preprint).. [DOI: 10.2196/preprints.32331]

BACKGROUND

Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings.

OBJECTIVE

This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine “Google Scholar,” and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games).

RESULTS

From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (<i>P</i>=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (<i>P</i>=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (<i>P</i>=.003).

CONCLUSIONS

Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs.

CLINICALTRIAL

PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969

Effectiveness of Virtual Reality Rehabilitation in Persons with Multiple Sclerosis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Multiple Sclerosis (MS) is a chronic disease with physical, cognitive, and psychosocial impairments. Virtual Reality (VR) has been used as an innovative tool in neurological rehabilitation. There are promising new studies that have used commercial video games consoles for the rehabilitation of people with MS.

OBJECTIVES

The aim of this systematic review is to summarize the effectiveness of using VR on functional mobility, fatigue, quality of life and balance in people with MS, compared with conventional exercises or no intervention.

METHODS

Six databases (Scielo, Lilacs, Pubmed, Cochrane library, Embase and PEDro) were searched using some of following terms: "Virtual reality" AND "Multiple sclerosis" AND " randomized controlled trial". Two reviewers performed the search, selection, and extraction of data from the studies. The methodological quality of the articles was assessed using the PEDro scale and the risk of bias was independently assessed by two reviewers using the Cochrane Collaboration Risk of Bias tool. Mean differences and confidence intervals were combined and calculated in meta-analysis.

RESULTS

Nine randomized clinical trials were included, with a total sample of 424 participants. In general, functional mobility presented similar improvement between groups, while for fatigue, quality of life and balance, VR promoted improvement equal to or greater than the conventional exercises. The meta-analysis confirmed that for functional mobility, VR does not promote significant improvement, while for fatigue, quality of life and balance, VR promotes superior improvement.

CONCLUSION

This systematic review demonstrated a positive effect of using VR in people with MS in relation to fatigue, quality of life and balance, compared to the conventional exercises. For functional mobility, VR associated or not with conventional exercises does not seem to bring additional benefits. Larger and methodologically robust studies are need.

OTHER

There was no funding for this systematic review. PROSPERO Registration Number CRD42021226471.

Modern Technologies in the Rehabilitation of Patients with Multiple Sclerosis and Their Potential Application in Times of COVID-19

Background and Objectives: The COVID-19 pandemic required the adoption of new technologies to improve access to healthcare at an unprecedented speed, as social distancing became mandatory. The aim of this systematic review was to analyze the effectiveness of using new technologies in the rehabilitation of multiple sclerosis (MS) patients and discuss their potential role during the COVID-19 pandemic. Material and Methods: The studies were identified by searching two online databases-PUBMED and Web of Science. Combinations of the key words "Multiple sclerosis" and "e-health"; "Multiple sclerosis" and "virtual reality"; "Multiple sclerosis" and "telerehabilitation"; "Multiple sclerosis" and "new technologies"; "Multiple sclerosis" and "tele-exercise" were used to find suitable publications. Results: A total of 17 studies were included. Although the overall number of participants in all the studies was 904, two of the studies were conducted on the same group. Thus, a total of 854 participants were involved in the studies included. All participants were diagnosed with MS. In 10 studies, participants had to be diagnosed according to the McDonald criteria. Of the included studies: five involved intervention at participants' home, six were conducted using Xbox Kinect, and seven studies reported no adverse outcomes. Conclusion: The review proves telerehabilitation to be an effective motivational tool to restore and maintain both physical and cognitive function in patients with MS. Remote communication technologies seem to be measures of high effectiveness in rehabilitating and supporting MS patients especially during the COVID-19 pandemic, as the traditional rehabilitation option is less accessible or in some cases inaccessible for these patients.

Digital therapeutics in neurology

Digital therapeutics (DTx) is a section of digital health defined by the DTx Alliance as “delivering evidence-based therapeutic interventions to patients that are driven by software to prevent, manage, or treat a medical disorder or disease. They are used independently or in concert with medications, devices, or other therapies to optimize patient care and health outcomes”. Chronic disabling diseases could greatly benefit from DTx. In this narrative review, we provide an overview of DTx in the care of patients with neurological dysfunctions.

Rehabilitation in multiple sclerosis in 2021

Patients with multiple sclerosis, despite advances in therapy, often suffer from locomotor impairment that limits their mobility and affect quality of life. Rehabilitation is part of the treatment of MS and has shown its beneficial effects in numerous studies. While traditional rehabilitation techniques remain in the limelight, new technologies are emerging and make it possible to improve the management of disabling symptoms. The aim of this update is to synthesize the new therapy techniques proposed in rehabilitation for patients with multiple sclerosis according to the symptoms as balance, gait, upper limb disorders, fatigue, spasticity and disease progression published over the past 5 years. With regard to balance and walking disorders, neuromotor rehabilitation, physical exercise, rhythmic auditory stimulation, gait robot training and exergaming are effective. Only physical exercise has shown a positive effect on fatigue management. Spasticity is improved by classic rehabilitation techniques however non-invasive brain stimulation are promising. The rehabilitation of upper limb dysfunctions uses various effective techniques such as the repetition of functional tasks in real or virtual situations. In case of a more severe disability, arm robots can be used to relearn the impaired movement. Action observation training in real or virtual situations is also effective. Finally, under certain conditions the constraint induced movement therapy is proposed. The effects of rehabilitation are not only positive on the pyramidal symptoms and fatigue but also increase neuroplasticity and perhaps a neuroprotective effect as shown in some studies.

Virtual Reality Rehabilitation and Exergames—Physical and Psychological Impact on Fall Prevention among the Elderly—A Literature Review

The present review is aimed at the effectiveness of virtual reality (VR) and exergames in the prevention of falls among the elderly. Falls become a significant problem in the aging population and lead to psychological, social, and physical impairment. Prevention of falls is crucial to the well-being of the elderly population and is one of the challenges of contemporary rehabilitation. Recently, in view of the threat of the SARS-CoV-2 pandemic, contactless methods of rehabilitation, including telerehabilitation, appear as valuable rehabilitation tools. This review is based on the PRISMA guidelines and was carried out in five databases: PubMed, Medline, Web of Science, Scopus, and PEDro. Twenty-one randomized controlled trials, focused on the application of VR and exergames in the prevention of falls, were included. This review suggests that VR training in rehabilitation appears to be a promising complement to traditional techniques of physiotherapy to improve specific physical outcomes. VR and exergames could be considered as a complement of standard physiotherapy and its possible continuation at home for elderly. However, further high-quality studies, with carefully designed protocols and proper blinding, are needed.

Upper limb rehabilitation interventions using virtual reality for people with multiple sclerosis: A systematic review

BACKGROUND

Research on Virtual Reality (VR) based motor rehabilitation for people with multiple sclerosis (MS) is rapidly growing in popularity, although few studies have focused on the upper limb (UL). The aims of this review were to investigate the effect of VR interventions on UL function in people with MS and determine if the type of VR intervention influences intervention effect.

METHOD

Five databases (IEEE Xplore, MEDLINE, ProQuest Central (Health & Medical Collection), Science Direct and Web of Science Core Collection) were searched using keywords that relating to MS, VR and UL.

RESULTS

Ten articles were included, six randomised controlled trials, three cohort studies and one pilot observational study. Both commercial and custom VR technologies were used in interventions, along with combination approaches using robotics, electrical stimulation and occupational therapy. Using the Nine Hole Peg Test, two studies found significant improvements within groups, one found that VR was more effective than another gaming approach. Significant improvements in other UL measures were in the Fugl-Meyer Assessment for the proximal arm; handgrip; perceived strength; Jebsen-Taylor Hand Function Test; Wolf Motor Function Test; active range of motion and trajectory measures after VR intervention. There were conflicting results regarding if VR was more effective than conventional approaches.

CONCLUSION

There is therefore some evidence that VR is effective in improving motor function in the UL, however, there is no clear consensus on which VR based approaches are the most effective, or the optimum intervention duration and intensity. Moreover, as many of the studies had non-immersive approaches it is hard to determine how effective immersion based approaches maybe in such specific context.

Sensor-based technology for upper limb rehabilitation in patients with multiple sclerosis: A randomized controlled trial

BACKGROUND

Sensor-based technological therapy devices may be good candidates for neuromotor rehabilitation of people with Multiple Sclerosis (MS), especially for treating upper extremities function limitations. The sensor-based device rehabilitation is characterized by interactive therapy games with audio-visual feedback that allows training the movement of shoulders, elbows, and wrist, measuring the strength and the active range of motion of upper limb, registering data in an electronic database to quantitatively monitoring measures and therapy progress.

OBJECTIVE

This study aimed to investigate the effects of sensor-based motor rehabilitation in add-on to the conventional neurorehabilitation, on increasing the upper limb functions of patients with MS.

METHODS

Thirty patients were enrolled in the study and randomly assigned to the experimental group and the control group. The training consisting of twelve sessions of upper limb training was compared with twelve sessions of upper limb sensory-motor training, without robotic support. Both rehabilitation programs were performed for 40 minutes three times a week, for 4 weeks, in addition to conventional therapy. All patients were evaluated at the baseline (T0) and after 4 weeks of training (T1).

RESULTS

The within-subject analysis showed a statistically significant improvement in both groups, in the Modified Barthel Index and in the Rivermead Mobility Index scores and a significant improvement in Multiple Sclerosis Quality of Life-54 in the experimental. The analysis of effectiveness revealed that, compared with baseline (T0), the improvement percentage in all clinical scale scores was greater in the experimental group than the control group.

CONCLUSIONS

Proposed training provides an intensive and functional-oriented rehabilitation that objectively evaluates achieved progress through exercises. Therefore, it can represent a good complementary strategy for hand rehabilitation in MS patients.