The Effect of Virtual Reality on the Ability to Perform Activities of Daily Living, Balance During Gait, and Motor Function in Parkinson Disease Patients: A Systematic Review and Meta-Analysis

Gait ecological assessment in persons with Parkinson's disease engaged in a synchronized musical rehabilitation program

Data on gait parameters during real-life activities and home rehabilitation programs for Persons with Parkinson's disease (PwPDs) are scarce. Although cueing has been shown to improve their gait in laboratory conditions, few studies have applied this technique in at-home rehabilitation programs. Our study aimed to explore the use of a real-time synchronized beat-step music program for at-home rehabilitation. We conducted a 1-month outdoor gait rehabilitation program called BeatPark (30 min/day, 5 days/week), with 25 PwPDs, using real-time synchronized, cued, music, and measurements through the BeatMove application. We demonstrated that real-world walking with BeatMove exhibited improved gait parameters both within and across sessions. These improvements were further confirmed by the Six-Minute Walk Test conducted in silence in the laboratory before and after the program. Measures in real life are unique tools to enhance rehabilitation programs. Future research incorporating a control group will be essential to fully validate these encouraging findings.

Cognition and Activity of Daily Living Function in people with Parkinson's disease

The ability to perform activities of daily living (ADL) function is a multifaceted construct that reflects functionality in different daily life situations. The loss of ADL function due to cognitive impairment is the core feature for the diagnosis of Parkinson's disease dementia (PDD). In contrast to Alzheimer's disease, ADL impairment in PD can be compromised by various factors, including motor and non-motor aspects. This narrative review summarizes the current state of knowledge on the association of cognition and ADL function in people with PD and introduces the concept of "cognitive ADL" impairment for those problems in everyday life that are associated with cognitive deterioration as their primary cause. Assessment of cognitive ADL impairment is challenging because self-ratings, informant-ratings, and performance-based assessments seldomly differentiate between "cognitive" and "motor" aspects of ADL. ADL function in PD is related to multiple cognitive domains, with attention, executive function, and memory being particularly relevant. Cognitive ADL impairment is characterized by behavioral anomalies such as trial-and-error behavior or task step omissions, and is associated with lower engagement in everyday behaviors, as suggested by physical activity levels and prolonged sedentary behavior. First evidence shows that physical and multi-domain interventions may improve ADL function, in general, but the evidence is confounded by motor aspects. Large multicenter randomized controlled trials with cognitive ADL function as primary outcome are needed to investigate which pharmacological and non-pharmacological interventions can effectively prevent or delay deterioration of cognitive ADL function, and ultimately the progression and conversion to PDD.

Effectiveness of virtual reality in preventing falls in non-disabled older adults: A meta-analysis and systematic review

OBJECTIVE

This study was conducted to evaluate the effectiveness of virtual reality interventions in preventing falls among non-disabled older adults.

METHODS

We conducted a librarian-designed database search. Two researchers independently screened eligible studies. The Cochrane Handbook for Systematic Reviews of Interventions was used to assess the risk of bias in the included studies.

RESULTS

Virtual reality interventions can effectively improve gait and dynamic and static balance function, enhance lower limb muscle strength, and reduce the risk of falls in the non-disabled elderly. However, the effect of virtual reality on reducing the fear of falling remains controversial.

CONCLUSION

Virtual reality interventions can effectively prevent falls in nondisabled elderly individuals. Higher quality, larger sample size, and long-term follow-up studies are needed to further verify the long-term effectiveness of virtual reality training in preventing falls in non-disabled elderly individuals.

Effects of virtual reality versus motor imagery versus routine physical therapy in patients with parkinson's disease: a randomized controlled trial

BACKGROUND

Parkinson's Disease (PD) is the second most common progressive neurodegenerative disorder, mostly affecting balance and motor function caused mainly by a lack of dopamine in the brain. The use of virtual reality (VR) and motor imagery (MI) is emerging as an effective method of rehabilitation for people with Parkinson's disease. Motor imagery and virtual reality have not been compared in patients with Parkinson's disease. This randomized clinical trial is unique to compare the effects of virtual reality with routine physical therapy, motor imagery with routine physical therapy, and routine physical therapy alone on balance, motor function, and activities of daily living in patients with Parkinson's disease.

METHODS

A total of sixty patients with Parkinson's disease were randomized into three groups using lottery method; twenty with virtual reality therapy in addition to physical therapy (group A = VR + RPT), twenty with imagery therapy in addition to physical therapy (group B = MI + RPT), and twenty were treated with only routine physical therapy (group C = RPT). All patients were evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS) for motor function and activities of daily living, the Berg balance scale (BBS) for balance, and the Activities-specific Balance Confidence Scale (ABCs) for balance confidence at baseline, six and twelve weeks, and one month after treatment discontinuation. The one-way ANOVA was used to compare the outcomes between three groups, and the repeated measures ANOVA was used to compare the outcomes within each of the three groups at a significance level of p-value = 0.05.

RESULTS

According to UPDRS III, the VR + RPT group showed significant improvement in motor function, compared to the MI + RPT and RPT groups, as the Mean ± SD at baseline was 33.95 ± 3.501 and at the 12-week assessment was 17.20 ± 9.451 with a p-value = 0.001. In the VR + RPT group, the BBS score at baseline was 37.15 ± 3.437 and at 12th week was 50.10 ± 4.897 with a p-value = 0.019. Among the VR + RPT group, the ABCS score showed significant improvement as the M ± SD at baseline was 57.95 ± 4.629, and at the 12th week was 78.59 ± 6.386 with a p-value = 0.010. At baseline, the UPDRS II for activities of daily living in the VR + RPT group was 25.20 ± 3.036 and at 12th week it was 15.30 ± 2.364 with p-value of 0.000.

CONCLUSION

The current study found that the combination of VR and RPT proved to be the most effective treatment method for improving balance, motor function, and activities of daily living in patients with Parkinson's disease when compared to MI + RPT or RPT alone.

Comparing the effects of augmented virtual reality treadmill training versus conventional treadmill training in patients with stage II-III Parkinson's disease: the VIRTREAD-PD randomized controlled trial protocol

Background

Intensive treadmill training (TT) has been documented to improve gait parameters and functional independence in Parkinson's Disease (PD), but the optimal intervention protocol and the criteria for tailoring the intervention to patients' performances are lacking. TT may be integrated with augmented virtual reality (AVR), however, evidence of the effectiveness of this combined treatment is still limited. Moreover, prognostic biomarkers of rehabilitation, potentially useful to customize the treatment, are currently missing. The primary aim of this study is to compare the effects on gait performances of TT + AVR versus TT alone in II-III stage PD patients with gait disturbance. Secondary aims are to assess the effects on balance, gait parameters and other motor and non-motor symptoms, and patient's satisfaction and adherence to the treatment. As an exploratory aim, the study attempts to identify biomarkers of neuroplasticity detecting changes in Neurofilament Light Chain concentration T0-T1 and to identify prognostic biomarkers associated to blood-derived Extracellular Vesicles.

Methods

Single-center, randomized controlled single-blind trial comparing TT + AVR vs. TT in II-III stage PD patients with gait disturbances. Assessment will be performed at baseline (T0), end of training (T1), 3 (T2) and 6 months (T3, phone interview) from T1. The primary outcome is difference in gait performance assessed with the Tinetti Performance-Oriented Mobility Assessment gait scale at T1. Secondary outcomes are differences in gait performance at T2, in balance and spatial-temporal gait parameters at T1 and T2, patients' satisfaction and adherence. Changes in falls, functional mobility, functional autonomy, cognition, mood, and quality of life will be also assessed at different timepoints. The G*Power software was used to estimate a sample size of 20 subjects per group (power 0.95, α < 0.05), raised to 24 per group to compensate for potential drop-outs. Both interventions will be customized and progressive, based on the participant's performance, according to a predefined protocol.

Conclusion

This study will provide data on the possible superiority of AVR-associated TT over conventional TT in improving gait and other motor and non-motor symptoms in persons with PD and gait disturbances. Results of the exploratory analysis could add information in the field of biomarker research in PD rehabilitation.

Home-based exergaming to treat gait and balance disorders in patients with Parkinson's disease: A phase II randomized controlled trial

BACKGROUND

Exergaming has been proposed to improve gait and balance disorders in Parkinson's disease (PD) patients. We aimed to assess the efficacy of a home-based, tailored, exergaming training system designed for PD patients with dopa-resistant gait and/or balance disorders in a controlled randomized trial.

METHODS

We recruited PD patients with dopa-resistant gait and/or balance disorders. Patients were randomly assigned (1:1 ratio) to receive 18 training sessions at home by playing a tailored exergame with full-body movements using a motion capture system (Active group), or by playing the same game with the computer's keyboard (Control group). The primary endpoint was the between-group difference in the Stand-Walk-Sit Test (SWST) duration change after training. Secondary outcomes included parkinsonian clinical scales, gait recordings, and safety.

RESULTS

Fifty PD patients were enrolled and randomized. After training, no significant difference in SWST change was found between groups (mean change SWST duration [SD] -3.71 [18.06] s after Active versus -0.71 [3.41] s after Control training, p = 0.61). Some 32% of patients in the Active and 8% in the Control group were considered responders to the training program (e.g., SWST duration change ≥2 s, p = 0.03). The clinical severity of gait and balance disorders also significantly decreased after Active training, with a between-group difference in favor of the Active training (p = 0.0082). Home-based training induced no serious adverse events.

CONCLUSIONS

Home-based training using a tailored exergame can be performed safely by PD patients and could improve gait and balance disorders. Future research is needed to investigate the potential of exergaming.

The impact of virtual reality on manual dexterity of Parkinson's disease subjects: a systematic review

PURPOSE

To present the latest available evidence on the effects of a VR-based therapy on the manual dexterity of PD subjects.

MATERIALS AND METHODS

The search was conducted in PubMed, EMBASE, and PEDro databases. Were included in the systematic review Randomized Clinical Trials, Pilot and Feasibility studies published up to December 2020. The studies should include at least one of the following assessments: Box and Blocks Test, 9-Hole Peg Test; Purdue Pegboard Test. PEDro Scale was used to assess the methodological quality of the included studies.

RESULTS

Eight studies were included in the review. Most studies have shown an improvement in outcomes for manual dexterity, but most of them presented a high risk of bias with low methodological quality. A high heterogeneity was observed in the protocols used for each study.

CONCLUSION

The results suggest that VR-based therapy has great potential and feasibility to be used as a manual dexterity rehabilitation protocol in PD subjects. However, these results must be interpreted carefully and studies with greater methodological rigor must be conducted.Implications For RehabilitationRehabilitation programs using virtual reality seem to have greater adherence to the user.Immersive virtual reality systems seem to do better in manual dexterity than non-immersive systems.It is plausible to use virtual reality systems in telerehabilitation for manual dexterity training in subjects with Parkinson's' Disease.The use of Virtual Reality by the therapist in a rehabilitation program allows him to modulate the exercises, enabling a wide variety of therapeutic options.

Efficacy of virtual reality training on motor performance, activity of daily living, and quality of life in patients with Parkinson's disease: an umbrella review comprising meta-analyses of randomized controlled trials

OBJECTIVE

There are several meta-analyses of randomized controlled trials (RCTs) demonstrating the benefits of virtual reality (VR) training as an intervention for motor performance, activity of daily living (ADL) and quality of life (QoL) outcomes in patients with Parkinson's disease (PD). However, the aggregate evidence collected to date has not been thoroughly evaluated for strength, quality, and reproducibility. An umbrella review from published meta-analyses of RCTs was conducted to evaluate the strength and quality of existing evidence regarding the efficacy of VR training in improving the motor performance, ADL and QoL outcomes of patients with PD.

METHODS

PubMed, PsychInfo, Web of Science, and Scopus were searched to identify relevant meta-analysis of RCTs examining the effects of VR training on motor performance and quality of life outcomes in PD patients. We recalculated the effect sizes (Hedges'g) for VR training using DerSimonian and Laird (DL) random effects models. We further assessed between-study heterogeneity, prediction interval (PI), publication bias, small-size studies, and whether the results of the observed positive studies were better than would be expected by chance. Based on these calculations, the quality of evidence for each outcome was assessed by using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria.

RESULTS

Four meta-analysis with eight outcomes included in the umbrella review was recalculated effect size. Pooled results found VR training can large improve the basic balance ability, moderate improve the overall balance capacity and moderate improve the stride length in PD patients. For ADL and QoL, the effect sizes were pooled that suggested VR training can moderate improve ADL and QoL for PD patients. However, no statistically clear evidence was found in walking speed, motor function and gait function during VR training. The analyzed meta-analyses showed low-to-moderate methodological quality (AMSTAR2) as well as presented evidence of moderate-to-very low quality (GRADE). Tow adverse reactions were reported in the included meta-analyses.

CONCLUSIONS

In this umbrella review, a beneficial correlation between VR and balance ability, stride length, ADL and QoL in PD patients was discovered, especially for the very positive effect of VR on balance because of two of the eight outcomes related to balance ability showed large effect size. The observations were accompanied by moderate- to very low-quality rating evidence, supporting VR training as a practical approach to rehabilitation.

Metaverse: Evolving role in healthcare delivery and implications

Metaverse, or the immersive internet, is touted as the next considerable technology-led disruption on the horizon, which can potentially disrupt clinician-patient interactions, patient experience, innovation and research and development processes. Metaverse is still in the evolution phase, and its firm definition framework is a work in progress. Surgical training allows the trainees to mimic procedures and simulate cross-collaborations within time and space, shortening the learning cycles. Similarly, patient experiences can be built by creating unique experiences replicating the real world without constraints. At the same time, the care providers can foster greater empathy while serving the patients with regular or special specific needs per disease conditions.

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.

Effectiveness of exergaming-based interventions for mobility and balance performance in older adults with Parkinson's disease: systematic review and meta-analysis of randomised controlled trials

BACKGROUND

exergaming-based interventions (EbIs) have been proposed to improve older adults' mobility and balance performance. However, the effectiveness of such interventions for older adults with Parkinson's disease (OAPD) remains unclear.

METHODS

seven databases (Web of Science, Medline, Academic Search Premier, CINAHL Complete, PsycINFO, PsychARTICLE and PubMed) were searched up to 7 April 2022. We assessed mobility and balance performance between EbIs groups and control groups or traditional physical training interventions (TPTIs) groups by comparing the outcomes of the Timed Up and Go (TUG), 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), gait velocity, stride length and Functional Gait Assessment (FGA).

RESULTS

we scanned 1,190 articles and meta-analysed 19 trials (sample size = 781). In general, the results revealed statistical differences between EbIs groups and TPTIs groups in the TUG [mean difference (MD) = -1.030 s; 95% confidence interval (CI) = -2.029 to -0.031; P = 0.043; high quality of evidence], 6MWT (MD = 63.483 m; 95% CI = 9.542 to 117.425; P = 0.021; moderate quality of evidence), BBS (MD = 2.129; 95% CI = -1.293 to 2.965; P < 0.001; high quality of evidence) and FGA (MD = 2.099 95% CI = -0.306 to 3.893; P = 0.022; moderate quality of evidence). No significant difference was discovered between EbIs groups and TPTIs groups in enhancing gait velocity and stride length.

CONCLUSIONS

EbIs are statistically better than TPTIs in improving OAPD's performance in TUG, 6MWT, BBS and FGA, whereas only the change between EbIs and TPTIs in 6MWT can reach the value of minimal clinically important difference. Further studies are needed to better assess the effectiveness of exergaming-based interventions.

Update on Parkinson's Disease Rehabilitation

Parkinson's disease (PD) is the second most common neurodegenerative disorder. Although dopaminergic drugs are the mainstay for improving PD symptoms, there are still few effective disease-modifying therapies. With the increasing prevalence of PD and the rapid transition to an aging society, more emphasis needs to be placed on rehabilitation that could slow the disease progression combined with pharmacological therapy. In this review, we present an update on evidence related to rehabilitation programs for motor function, swallowing difficulty, and speech disorders in PD. Aerobic exercise, music therapy, dance, virtual reality, and non-invasive brain stimulation have been shown to improve motor function, and telerehabilitation could also be feasibly applied in PD. Recent studies have shown the effectiveness of expiratory muscle strengthening exercises and Lee Silverman Voice Treatment for swallowing difficulty and speech disorders, respectively. Although many rehabilitation programs have been tried, the evidence is still limited. Well-designed future randomized controlled trials with large numbers of participants are needed to establish evidence for rehabilitation in PD.

Efficacy and Moderators of Virtual Reality for Cognitive Training in People with Dementia and Mild Cognitive Impairment: A Systematic Review and Meta-Analysis

BACKGROUND

Mild cognitive impairment (MCI) and dementia result in cognitive decline which can negatively impact everyday functional abilities and quality of life. Virtual reality (VR) interventions could benefit the cognitive abilities of people with MCI and dementia, but evidence is inconclusive.

OBJECTIVE

To investigate the efficacy of VR training on global and domain-specific cognition, activities of daily living and quality of life. To explore the influence of priori moderators (e.g., immersion type, training type) on the effects of VR training. Adverse effects of VR training were also considered.

METHODS

A systematic literature search was conducted on all major databases for randomized control trial studies. Two separate meta-analyses were performed on studies with people with MCI and dementia.

RESULTS

Sixteen studies with people with MCI and four studies with people with dementia were included in each meta-analysis. Results showed moderate to large effects of VR training on global cognition, attention, memory, and construction and motor performance in people with MCI. Immersion and training type were found to be significant moderators of the effect of VR training on global cognition. For people with dementia, results showed moderate to large improvements after VR training on global cognition, memory, and executive function, but a subgroup analysis was not possible.

CONCLUSION

Our findings suggest that VR training is an effective treatment for both people with MCI and dementia. These results contribute to the establishment of practical guidelines for VR interventions for patients with cognitive decline.

Construction and Application of Virtual Reality-Based Sports Rehabilitation Training Program

This paper adopts virtual reality technology to conduct in-depth research and analysis on sports rehabilitation training, designs a corresponding sports rehabilitation training program, and applies it to practice. An AR algorithm based on dynamic target tracking under VSLAM is proposed. The algorithm can effectively reject dynamic targets in static scenes while ensuring that the virtual objects registered based on dynamic template target tracking are still in the world coordinate system of VSLAM. To facilitate patients' hand function rehabilitation training, this paper uses OpenPose for 2D gesture pose recognition, combines camera pose information and depth information provided by VSLAM to map key points of the hand into the world coordinate system, and then completes the interaction by collision detection algorithm. The virtual interaction module is implemented in this paper to meet the demand for multiuser off-site interaction in virtual training. This paper uses the Unity3D software and Photon Server server to create a VR virtual scene and design a user interaction mechanism to realize a system that supports multiple users to train together online, which effectively extends the application scope of the VR training system. The module utilizes Unity3D's VR development capabilities to develop VR virtual basketball gym scenes and single-player offline interaction mechanisms such as virtual user single shooter and shooter; then, Photon Server is used to design and implement a multiuser remote login system and a multiuser interpass mechanism, thus achieving the effect of multiplayer remote online interaction in the same VR space. Finally, the proposed module was validated, and the results proved the effectiveness of the sports rehabilitation training program.

The Category of Conventional Physiotherapy: The Case of Parkinson’s Disease Guidelines

This opinion paper reviews the use of the category of “conventional physiotherapy” (CPT) in Parkinson’s disease (PD)-relevant reviews and meta-analyses and points out serious inconsistencies within and among them. These are first discussed in general, leading to the conclusion that, in most cases, the category of CPT encompasses a range of incompatible interventions. This undermines previous conclusions about their superiority or inferiority relative to various other treatment modalities. Next, the update to the European Physiotherapy Guidelines is discussed in detail, since it treats CPT as a global and time-independent category per se, ascribing effects in various domains to it. This introduces several important biases into the findings presented in this publication. These are subsequently discussed, and it is concluded that the categorisation of various physiotherapy techniques under the umbrella term of CPT is empty, or even dangerous, and should be abandoned. Other categories are suggested as a replacement, including “Other Physiotherapy Techniques” and “Multimodal Training”.

Combined effects of virtual reality techniques and motor imagery on balance, motor function and activities of daily living in patients with Parkinson's disease: a randomized controlled trial

Background

Parkinson's disease (PD) is the second most prevalent neurodegenerative disorder, impairing balance and motor function. Virtual reality (VR) and motor imagery (MI) are emerging techniques for rehabilitating people with PD. VR and MI combination have not been studied in PD patients. This study was conducted to investigate the combined effects of VR and MI techniques on the balance, motor function, and activities of daily living (ADLs) of patients with PD.

Methods

This study was a single-centered, two-armed, parallel-designed randomized controlled trial. A total of 44 patients of either gender who had idiopathic PD were randomly allocated into two groups using lottery methods. Both groups received Physical therapy (PT) treatment, while the experimental group (N: 20) received VR and MI in addition to PT. Both groups received assigned treatment for three days a week on alternate days for 12 weeks. The Unified Parkinson’s Disease Rating Scale (UPDRS) (parts II and III), Berg Balance Scale (BBS), and Activities-specific Balance Confidence (ABC) Scale were used as outcome measures for motor function, balance, and ADLs. The baseline, 6^th, and 12^th weeks of treatment were assessed, with a 16^th week follow-up to measure retention. The data was analysed using SPSS 24.

Results

The experimental group showed significant improvement in motor function than the control group on the UPDRS part III, with 32.45±3.98 vs. 31.86±4.62 before and 15.05±7.16 vs. 25.52±7.36 at 12-weeks, and a p-value < 0.001. At 12 weeks, the experimental group's BBS scores improved from 38.95±3.23 to 51.36±2.83, with p-value < 0.001. At 12 weeks, the experimental group's balance confidence improved considerably, from 59.26±5.87to 81.01±6.14, with a p-value of < 0.001. The experimental group's ADL scores improved as well, going from 22.00±4.64 to 13.07±4.005 after 12 weeks, with a p-value of < 0.001.

Conclusion

VR with MI techniques in addition to routine PT significantly improved motor function, balance, and ADLs in PD patients compared to PT alone.

Trial registration

IRCT20200221046567N1. Date of registration: 01/04/2020

The effectiveness of virtual reality for rehabilitation of Parkinson disease: an overview of systematic reviews with meta-analyses

BACKGROUND

An increasing number of systematic reviews (SRs) and meta-analyses (MAs) of clinical trials have begun to investigate the effects of virtual reality (VR) in patients with Parkinson disease (PD). The aim of this overview was to systematically summarize the current best evidence for the effectiveness of VR therapy for the rehabilitation of people with PD.

METHODS

We searched SR-MAs based on randomized controlled trials (RCTs) for relevant literature in PubMed, Embase, and Cochrane library databases for systematic reviews from inception to December 5, 2020, and updated to January 26, 2022. The methodological quality of included SR-MAs was evaluated with the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2), and the certainty of evidence for outcomes with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: effect size of VR therapy versus active intervention (AT), clinical outcome area, number of trials, statistical significance, and certainty of evidence.

RESULTS

From a total of 585 reports, 12 reviews were identified, of which only one was rated moderate quality, three were rated low quality, and eight were rated critically low quality by AMSTAR 2. Compared with AT, VR therapy induced increased benefits on stride/step length, balance, and neuropsychiatric symptoms. Compared with passive intervention (PT), VR therapy had greater effects on gait speed, stride/step length, balance, activities of daily living, and postural control in people with PD. Certainty of evidence varied from very low to moderate.

CONCLUSIONS

We found the methodological quality of the reviews was poor, and certainty of the most evidence within them was low to very low. We were therefore unable to conclude with any confidence that, in people with PD, VR therapy is harmful or beneficial for gait, balance, motor function, quality of life, activities of daily living, cognitive function, neuropsychiatric symptoms, and postural control. In the future, rigorous-designed, high-quality RCTs with larger sample sizes are needed to further verify the effectiveness of VR therapy in the treatment of PD.

Integration of Virtual Reality into Transcranial Magnetic Stimulation Improves Cognitive Function in Patients with Parkinson's Disease with Cognitive Impairment: A Proof-of-Concept Study

BACKGROUND

Emerging evidence has indicated the positive effects of repetitive transcranial magnetic stimulation (rTMS) on patients with Parkinson's disease (PD) for the treatment of mild cognitive impairment (MCI).

OBJECTIVE

Investigating whether combining virtual reality (VR) training with rTMS can further enhance cognitive improvement induced by rTMS treatment.

METHODS

We randomly assigned 40 patients with PD and MCI into three groups, namely the rTMS-VR group (n = 13), rTMS group (n = 11), and sham rTMS group (n = 16). rTMS was administered as 10 consecutive sessions of intermittent theta burst stimulation (iTBS) over the left dorsolateral prefrontal cortex. In the rTMS-VR group, VR training was administered immediately after each rTMS session. Cognitive function was measured using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Montreal Cognitive Assessment (MoCA) at baseline, immediately after intervention, and at 3-month follow-up.

RESULTS

Compared with the rTMS group, the rTMS-VR group exhibited significantly more improvements in total and delayed memory scores of the RBANS and the visuospatial/executive function score of the MoCA after intervention (p = 0.000∼0.046) and the delayed memory score of the RBANS at 3-month follow-up (p = 0.028).

CONCLUSION

The integrated rTMS-VR protocol achieved a superior outcome in global cognitive function, more effectively enhancing working memory and visuospatial executive function than did the rTMS protocol alone. The combination of VR and rTMS can be an effective regimen for improving the cognitive function of patients with PD.

Effect of virtual reality rehabilitation on functional outcomes for return-to-work patients with Parkinson's disease: An umbrella review of systematic reviews

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disease characterized by loss of substantia nigra neurons with deficiency of dopamine. The main symptoms are tremor, rigidity and bradykinesia. Rehabilitation has an important role in the treatment of this condition and virtual reality (VR) is one of the most recent tools.

OBJECTIVE

The purpose of this umbrella review is to evaluate the effectiveness of VR systems on gait control for return to work in patients with PD.

METHODS

The electronic search, for reviews and meta-analysis studies that investigated the effectiveness of VR on gait control in PD patients, was performed through December 2021 using the following databases: PubMed, Scopus, PEDro, and Google Scholar. Mesh terms used were: Job integration/reintegration OR return-to-work AND Parkinson's disease AND virtual reality OR exergame. No limit on the year of publication of the article was used.

CONCLUSIONS

A total of 14 articles were included in our analysis. The included evidence shows a stride length improvement in patients treated with VR compared to conventional active treatments. No difference was found in walking speed. Also, the included articles show an improvement on various measures of balance, motor function and severity of PD motor symptoms. In addition, the literature shows an improvement in the quality of life and neuropsychiatric symptoms in patients undergoing VR rehabilitation training.

RESULTS

he results of our study suggest that VR rehabilitation improves gait performance, particularly stride length, thus being able to provide an improvement in the quality of life and a more effective return to work training in patients with PD.

Parkinson's disease and virtual reality rehabilitation: cognitive reserve influences the walking and balance outcome

INTRODUCTION

Parkinson's disease (PD) is a neurodegenerative pathology characterized by motor and non-motor symptoms that often lead to several impairments. Many studies show the efficacy of different rehabilitation protocols aimed to improve balance and gait functions in PD patients. However, multiple factors may influence rehabilitation outcome. Recently, it has been observed as the cognitive reserve (CR) may influence the rehabilitation outcome, helping to address the patient toward technological or conventional rehabilitation. Our study investigated how CR may affect motor rehabilitation outcomes in PD patients who undergo virtual reality (VR) rehabilitation, aimed at improving walking and balance.

MATERIALS AND METHODS

Thirty patients affected by idiopathic PD were enrolled. Patients underwent 12 sessions VR training, over 6 weeks (45 min). Six-Minute Walk Test (6MWT) and Berg Balance Scale (BBS) were used to assess walking and balance, respectively. CR was assessed by Cognitive Reserve Index questionnaire (CRIq).

RESULTS

Significant correlations between CR and change from baseline in walking and balance measures were found, with a significant positive correlation between CRIq and 6MWT (r=0.50, p=0.01) and between CRIq and BBS (r=0.41, p=0.04).

DISCUSSION

Our results showed that PD patients with higher CR treated with VR improved significantly more in their balance and walking distance than those with lower CR. The current study suggests that VR when aimed to improve balance and walking in PD patients is more effective in patients with higher CR.

Virtual reality balance training to improve balance and mobility in Parkinson's disease: a systematic review and meta-analysis

BACKGROUND

In the last few years, virtual reality (VR) has been increasingly used to strengthen the effect of balance training (BT) in Parkinson's disease (PD).

OBJECTIVE

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the effects of VR-BT relative to BT alone for improving balance and mobility PD subjects with balance/mobility difficulties.

METHODS

Four electronic databases were searched: two reviewers independently selected RCTs, extracted data, and applied the Cochrane risk-of-bias tool for randomized trials (version 2) and the GRADE framework for assessing the certainty of evidence. Primary outcomes were balanced (Berg Balance Scale-BBS), mobility (Timed Up and Go-TUG) and walking speed. Secondary outcomes were falls, walking distance and stability, spatial gait parameters, balance confidence, sensory integration ability, motor signs and quality of life.

RESULTS

We included 22 studies (901 patients). Meta-analysis on fourteen trials (430 patients) showed a mean difference (MD) of 2.09 points (95% confidence interval [CI] 0.86-3.33) on BBS favoring VR-BT compared to BT (low certainty evidence). Subgroup analyses showed higher balance improvement in most affected subjects (moderate certainty evidence) and using VR rehabilitation-specific systems vs. VR non-specific systems. Eight trials (236 patients) assessing mobility showed a MD of 1.55 s (95% CI 0.04-3.06) on TUG favoring VR-BT (very low certainty evidence). No differences were observed in walking speed. Estimated effects were not maintained for any outcome at follow-up.

CONCLUSIONS

This review suggests that VR-BT is more effective than BT to improve balance in PD subjects immediately after training, particularly in individuals with higher postural instability at baseline.

Virtual immersive sensorimotor training (VIST) in collegiate soccer athletes: A quasi-experimental study

A burgeoning area of innovation in sports is the use of extended realities to provide athletes with novel training environments. Evidence has demonstrated that virtual environments can be useful therapeutic tools with demonstrated positive outcomes. The purpose of this pilot investigation was to determine the effects of virtual immersive sensorimotor training intervention by quantifying 1) the training effect measured via change in performance pre-to post-intervention on the virtual reality exercises, 2) the difference in the in clinical measures of functional sensorimotor control, 3) the injury incidence rate, and 4) on-field performance during soccer competitions. Statistical analyses were used to describe differences between an experimental and a control group. Participants were recruited from the men and women's soccer teams at two universities in the United States. Participants at one university were in the experimental group (n = 78) and received virtual immersive sensorimotor training, consisting of nine novel exercises in headset virtual reality, twice each week for six weeks. Participants at the second university were in the control group (n = 52). The virtual exercises were developed with reference to the rehabilitative principles of neuroplasticity to train various neurologic processes, contributing to overall sensorimotor control. This includes vestibular, visual and oculomotor activities, cervical neuromotor control training, movement coordination, and postural/balance exercises. The results indicate significant positive training effects pre-to post-intervention in seven of the nine training exercises (p ≤ 0.005) and improvement in clinical tests of cervical neuromotor control, balance, and inspection time (p ≤ 0.009) in the experimental group compared to the control. One of the virtual training exercises was positively associated with on-field performance (p = 0.022). No differences in injury rate or overall on-field performance metrics between the experimental and control were detected. This research study provides evidence of training and positive transfer from virtual to real-world environments, supporting the use of these novel virtual exercises to improve measures of sensorimotor control in healthy soccer athletes.